High membrane transport status on peritoneal dialysis is not associated with reduced survival following transfer to haemodialysis.

BACKGROUND: High transporter status is associated with reduced survival of patients receiving peritoneal dialysis (PD). This may be due primarily to the development of complications related to the PD process, in which case the survival disadvantage may not persist following transfer to haemodialysis (HD). In this study, we aimed to assess the impact of peritoneal membrane transporter status on patient survival and the likelihood of return to PD following transfer from PD to HD. METHODS: The Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry was searched to identify all patients between 1 April 1999 and 31 March 2004 who had received PD and subsequently transferred to HD, in whom an incident 4 h dialysate: plasma creatinine ratio was recorded. A Cox proportional hazards model was used to identify factors significantly associated with patient and technique survival after commencement of HD. RESULTS: A total of 918 patients were included in the analysis. On multivariate Cox regression analysis there was no difference in survival between transport groups relative to the reference group of low average transporters (adjusted hazard ratio (HR) 0.71, 95% CI 0.42-1.19, P = 0.19, HR 0.94, 95% CI 0.63-1.38, P = 0.73 and HR 0.24, 95% CI 0.06-1.01, P = 0.051 for high, high average and low transporter groups, respectively). Significant predictors of mortality were duration of PD more than 22 months (HR 2.32, 95% CI 1.24-4.33, P = 0.01), increasing age, late referral to a nephrologist and a history of diabetes mellitus. The likelihood of returning to PD was increased if initial PD technique failure was due to mechanical complications compared with all other causes of failure [HR 3.65 (95% CI 2.78-4.79) P < 0.001] and decreased with higher body mass index [HR 0.97 per kg/m(2) (95% CI 0.94-0.99), P = 0.01] and the 4 h dialysate: plasma creatinine ratio considered as a continuous variable [4 h D:P Cr; HR 0.32 per unit (95% CI 0.12-0.89), P = 0.03]. CONCLUSIONS: The survival disadvantage associated with high peritoneal membrane transport status during PD treatment does not persist following transfer to HD. Early transfer to HD may be beneficial in this patient group.     

Effect of previously failed kidney transplantation on peritoneal dialysis outcomes in the Australian and New Zealand patient populations.

BACKGROUND: There is limited information about the outcomes of patients commencing peritoneal dialysis (PD) after failed kidney transplantation. The aim of the present study was to compare patient survival, death-censored technique survival and peritonitis-free survival between patients initiating PD after failed renal allografts and those after failed native kidneys. METHODS: The study included all patients from the ANZDATA Registry who started PD between April 1, 1991 and March 31, 2004. Times to death, death-censored technique failure and first peritonitis episode were examined by multivariate Cox proportional hazards models. For all outcomes, conditional risk set models were utilized for the multiple failure data, and analyses were stratified by failure order. Standard errors were calculated by using robust variance estimation for the cluster-correlated data. RESULTS: In total, 13,947 episodes of PD were recorded in 23,579 person-years. Of these, 309 PD episodes were started after allograft failure. Compared with PD patients who had never undergone kidney transplantation, those with failed renal allografts were more likely to be younger, Caucasian, New Zealand residents and life-long non-smokers with lower body mass index (BMI), poorer initial renal function and a longer period from commencement of the first renal replacement therapy to PD. On multivariate analysis, PD patients with failed kidney transplants had comparable patient mortality [weighted hazards ratio (HR) 1.09, 95% confidence interval (CI) 0.81-1.45, P = 0.582], death-censored technique failure (adjusted HR 0.91, 95% CI 0.75-1.10, P = 0.315) and peritonitis-free survival (adjusted HR 0.92, 95% CI 0.72-1.16, P = 0.444) with those PD patients who had failed native kidneys. Similar findings were observed in a subset of patients (n = 5496) for whom peritoneal transport status was known and included in the models as a covariate. CONCLUSION: Patients commencing PD after renal allograft failure experienced outcomes comparable with those with failed native kidneys. PD appears to be a viable option for patients with failed kidney allografts.     

Is a single time point C-reactive protein predictive of outcome in peritoneal dialysis patients?

C-reactive protein is the prototype marker of inflammation and has been shown to predict mortality in hemodialysis patients. However, it remains uncertain as to whether a single C-reactive protein level has similar prognostic significance in peritoneal dialysis patients. A single high-sensitivity C-reactive protein (hs-CRP) level was measured in 246 continuous ambulatory peritoneal dialysis patients without active infections at study baseline together with indices of dialysis adequacy, echocardiographic parameters (left ventricular mass index, left ventricular dimensions, and ejection fraction), nutrition markers (serum albumin, dietary intake, and subjective global assessment) and biochemical parameters (hemoglobin, lipids, calcium, and phosphate). The cohort was then followed-up prospectively for a median of 24 mo (range, 2 to 34 mo), and outcomes were studied in relation to these parameters. Fifty-nine patients died (36 from cardiovascular causes) during the follow-up period. The median hs-CRP level was 2.84 mg/L (range, 0.20 to 94.24 mg/L). Patients were stratified into tertiles according to baseline hs-CRP, namely those with hs-CRP < or = 1.26 mg/L, 1.27 to 5.54 mg/L, and > or = 5.55 mg/L. Those with higher hs-CRP were significantly older (P < 0.001), had greater body mass index (P < 0.001), higher prevalence of coronary artery disease (P = 0.003), and greater left ventricular mass index (P < 0.001). One-year overall mortality was 3.9% (lower) versus 8.8% (middle) versus 21.3% (upper tertile) (P < 0.0001). Cardiovascular death rate was 2.7% (lower) versus 5.2% (middle) versus 16.2% (upper tertile) (P < 0.0001). Multivariable Cox regression analysis showed that every 1 mg/L increase in hs-CRP was independently predictive of higher all-cause mortality (hazard ratio [HR], 1.02; 95% CI, 1.01 to 1.04; P = 0.002) and cardiovascular mortality (HR, 1.03; 95% CI, 1.01 to 1.05; P = 0.001) in peritoneal dialysis patients. Other significant predictors for all-cause mortality included age (HR, 1.07; 95% CI, 1.04 to 1.10), gender (HR, 0.49; 95% CI, 0.27 to 0.90), atherosclerotic vascular disease (HR, 2.65; 95% CI, 1.46 to 4.80), left ventricular mass index (HR, 1.01; 95% CI, 1.00 to 1.01) and residual GFR (HR, 0.53; 95% CI, 0.38 to 0.75). Age (HR, 1.06; 95% CI, 1.02 to 1.10), history of heart failure (HR, 3.31; 95% CI, 1.36 to 8.08), atherosclerotic vascular disease (HR, 3.20; 95% CI, 1.43 to 7.13), and residual GFR (HR, 0.57; 95% CI, 0.38 to 0.86) were also independently predictive of cardiovascular mortality. In conclusion, a single, random hs-CRP level has significant and independent prognostic value in PD patients.     

Elevated white cell count at commencement of peritoneal dialysis predicts overall and cardiac mortality

BACKGROUND: Higher total white blood cell counts (WCC) have been shown in the general population to be strongly and independently predictive of coronary heart disease and all-cause mortality. The aim of the present study was to evaluate the prognostic value of WCC in patients commencing peritoneal dialysis (PD). METHODS: A cohort of 323 patients (mean age 55.1 +/- 17.7 years, 54% male, 81% Caucasian) commencing PD at the Princess Alexandra Hospital between January 1, 1998 and March 31, 2003 were prospectively followed until death, completion of PD therapy, or otherwise to the end of the study (January 2, 2004), at which point data were censored. Individuals with failed renal transplants (N= 17) and those with acute infections at the time of PD onset (N= 12) were not included. A multivariate Cox's proportional hazards model was applied to calculate hazard ratios and adjusted survival curves for time to death or cardiac death, adjusting for baseline demographic, clinical, and laboratory characteristics. RESULTS: Median actuarial patient survival was 3.9 years [95% confidence interval (CI) 3.2-4.7 years]. The highest quartile of WCC (>9.4 x 10(9)/L) was significantly and independently associated with increased risks of both death from all causes [adjusted hazard ratio (HR) 2.27, 95% CI 1.09-4.74, P < 0.05] and cardiac death (HR 3.75, 95% CI 1.2-11.8, P < 0.05). Other adverse risk factors included older age, lower serum albumin, and the presence of coronary artery disease. Similar associations were found between mortality and PMN count, but not lymphocyte count. CONCLUSION: Elevated baseline WCC or PMN count at the commencement of PD (in the absence of acute infection) strongly predicts all-cause and cardiovascular mortality. These data suggest that new PD patients with higher WCC may warrant closer monitoring and extra attention to modifiable cardiovascular risk factors.     

Dialysis outcomes in Colombia (DOC) study: a comparison of patient survival on peritoneal dialysis vs hemodialysis in Colombia

The goal of the Dialysis Outcomes in Colombia (DOC) study was to compare the survival of patients on hemodialysis (HD) vs peritoneal dialysis (PD) in a network of renal units in Colombia. The DOC study examined a historical cohort of incident patients starting dialysis therapy between 1 January 2001 and 1 December 2003 and followed until 1 December 2005, measuring demographic, socioeconomic, and clinical variables. Only patients older than 18 years were included. As-treated and intention-to-treat statistical analyses were performed using the Kaplan-Meier method and Cox proportional hazard model. There were 1094 eligible patients in total and 923 were actually enrolled: 47.3% started HD therapy and 52.7% started PD therapy. Of the patients studied, 751 (81.3%) remained in their initial therapy until the end of the follow-up period, death, or censorship. Age, sex, weight, height, body mass index, creatinine, calcium, and Subjective Global Assessment (SGA) variables did not show statistically significant differences between the two treatment groups. Diabetes, socioeconomic level, educational level, phosphorus, Charlson Co-morbidity Index, and cardiovascular history did show a difference, and were less favorable for patients on PD. Residual renal function was greater for PD patients. Also, there were differences in the median survival time between groups: 27.2 months for PD vs 23.1 months for HD (P=0.001) by the intention-to-treat approach; and 24.5 months for PD vs 16.7 months for HD (P<0.001) by the as-treated approach. When performing univariate Cox analyses using the intention-to-treat approach, associations were with age > or =65 years (hazard ratio (HR)=2.21; confidence interval (CI) 95% (1.77-2.755); P<0.001); history of cardiovascular disease (HR=1.96; CI 95% (1.58-2.90); P<0.001); diabetes (HR=2.34; CI 95% (1.88-2.90); P<0.001); and SGA (mild or moderate-severe malnutrition) (HR=1.47; CI 95% (1.17-1.79); P=0.001); but no association was found with gender (HR=1.03, CI 95% 0.83-1.27; P=0.786). Similar results were found with the as-treated approach, with additional associations found with Charlson Index (0-2) (HR=0.29; Cl 95% (0.22-0.38); P<0.001); Charlson Index (3-4) (HR=0.61; Cl 95% (0.48-0.79); P<0.001); and SGA (mild-severe malnutrition) (HR=1.43; Cl 95% (1.15-1.77); P<0.001). Similarly, the multivariate Cox model was run with the variables that had shown association in previous analyses, and it was found that the variables explaining the survival of patients with end-stage renal disease in our study were age, SGA, Charlson Comorbidity Index 5 and above, diabetes, healthcare regimes I and II, and socioeconomic level 2. The results of Cox proportional risk model in both the as-treated and intention-to-treat analyses showed that there were no statistically significant differences in survival of PD and HD patients: intention-to-treat HD/PD (HR 1.127; CI 95%: 0.855-1.484) and as-treated HD/PD (HR 1.231; CI 95%: 0.976-1.553). In this historical cohort of incident patients, there was a trend, although not statistically significant, for a higher (12.7%) adjusted mortality risk associated with HD when compared to PD, even though the PD patients were poorer, were more likely to be diabetic, and had higher co-morbidity scores than the HD patients. The variables that most influenced survival were age, diabetes, comorbidity, healthcare regime, socioeconomic level, nutrition, and education.     

Increases in peritoneal small solute transport in the first month of peritoneal dialysis predict technique survival

BACKGROUND: Peritoneal transport of small solutes generally increases during the first month of peritoneal dialysis (PD). The aim of this study was to prospectively evaluate the ability of the peritoneal equilibration test (PET), carried out 1 and 4 weeks after the commencement of PD, to predict subsequent technique survival. METHODS: Fifty consecutive patients commencing PD at the Princess Alexandra Hospital between 1 February 2001 and 31 May 2003 participated in the study. Paired 1 week and 1 month PET data were collated and correlated with subsequent technique survival. RESULTS: A significant increase was observed in the dialysate : plasma creatinine ratio at 4 h (D/P Cr) between 1 and 4 weeks after the onset of PD (0.55 +/- 0.12 vs 0.66 +/- 0.11, P <0.001). Mean death-censored technique survival was superior in patients who experienced > or =20% rise in D/P Cr during the first month of PD compared with those who did not (2.3 +/- 0.2 vs 1.6 +/- 0.2 years, P <0.05). Using a multivariate Cox proportional hazards model analysis, the significant independent predictors of death-censored technique survival were an increase in D/P Cr of greater than 20% during the first month (adjusted hazard ratio [HR] 0.20, 95% CI 0.05-0.75), the absence of diabetes mellitus, the absence of ischaemic heart disease, body mass index and baseline peritoneal creatinine clearance. CONCLUSIONS: A 20% or greater rise in D/P Cr during the first month of commencing PD is independently predictive of PD technique survival. Further investigations of the mechanisms underlying this phenomenon are warranted.     

The impact of early-diagnosed new-onset post-transplantation diabetes mellitus on survival and major cardiac events

The impact of early-diagnosed new-onset post-transplantation diabetes mellitus (PTDM) on cardiovascular (CV) disease is not well described. The objectives of the present prospective single-center observational study were to assess the long-term effects of early-diagnosed new-onset PTDM on major cardiac events (MCE; cardiac death or nonfatal acute myocardial infarction) and patient survival. Diabetic status and CV risk factors were assessed in 201 consecutive renal allograft recipients 3 months after transplantation (baseline) during a period of 16 months (1995-96). Follow-up data until January 1, 2004 were obtained from the Norwegian Renal Registry. The 8-year (range 7-9 years) cumulative incidence of MCEs was 7% (nine out of 138) in recipients without diabetes, 20% (seven out of 35) in patients with new-onset PTDM and 21% (six out of 28) in patients with diabetes mellitus before transplantation (DM). Proportional hazards regression analyses (forward stepwise regression) revealed that patients with PTDM had an approximately three-fold increased risk of MCEs as compared with nondiabetic patients (hazard ratio (HR)=3.27, 95% confidence interval (CI)=1.22-8.80, P=0.019). A total of 61 patients (30%) died. Eight-year patient survival was 80% in the nondiabetic group, 63% in the PTDM group and 29% in the DM group, respectively. Pretransplant diabetes (HR=5.09, 95% CI=2.60-9.96, P<0.001), age (HR=1.03, 95% CI=1.01-1.05, P=0.016), cytomegalovirus (CMV) infection (HR=2.66, 95% CI=1.27-5.53, P=0.009), and creatinine clearance (HR=0.98, 95% CI=0.96-1.00, P=0.046), but not PTDM (HR=1.20, 95% CI=0.58-2.49, P=0.621), were independent predictors of death in the multiple Cox regression model. Early-diagnosed PTDM is a predictor of MCEs, but not of all-cause mortality, the first 8 years after renal transplantation.     

Effect of the interaction between estimated glomerular filtration rate and serum uric acid on all-cause and cardiovascular mortality in patients on peritoneal dialysis

Objective To explore the effect of the interaction between estimated glomerular filtration rate (eGFR) and serum uric acid (SUA) on all-cause and cardiovascular mortality in patients on peritoneal dialysis (PD). Methods Patients who performed PD catheterization at the PD center of the First Affiliated Hospital of Sun Yat-sen University and had initiated PD therapy for over 3 months from January 2006 to December 2016 were enrolled and followed up until December 2018. Demographic data, baseline clinical and laboratory examination results of the patients were collected. Kaplan-Meier survival curve and Cox regression analysis were used to explore the correlation between SUA and all-cause mortality, cardiovascular mortality in different eGFR groups of PD patients. Results A total of 2 124 PD patients were enrolled with age of (47.0±15.2) years, among whom 1 269 patients were male and 536 patients had diabetes. The SUA level was (429±96) μmol/L and the median level of eGFR was 6.69(5.17, 8.61) ml?min-1?(1.73 m2)-1. After a median follow-up time of 42 months, 554 patients died, among whom 275 patients were cardiovascular death. The Cox regression analysis revealed that there was a significant interaction between eGFR and SUA on all-cause mortality (P=0.043). The Kaplan-Meier curve showed that the tertile 1 (SUA＜384 μmol/L) and tertile 3 (SUA＞460 μmol/L) group had significantly higher all-cause mortality (P=0.009) than the reference group of tertile 2 (SUA 384-460 μmol/L) in the higher eGFR group [eGFR＞6.69 ml?min-1?(1.73 m2)-1]but not in the lower eGFR. After adjusting for relevant demographic data, complications, biochemical results and other variables, in patients with higher eGFR, the risk of all-cause mortality increased by 0.2% (HR=1.002, 95%CI 1.000-1.003, P=0.019) for every 1 μmol/L increase in SUA. In addition, compared with the tertile 2 reference group, the tertile 3 group was independently correlated with higher risk of all-cause mortality (HR=1.670, 95%CI 1.242-2.245, P=0.001). Conclusions The eGFR and SUA level significantly interacts with all-cause mortality, and the higher SUA level in higher eGFR group is an independent risk factor for all-cause mortality in PD patients.     

Risk factors for mortality in diabetic peritoneal dialysis patients

Objective To investigate the risk factors of all-cause mortality in diabetic patients on peritoneal dialysis (PD). Methods As a single-center retrospective cohort study, all incident PD patients who were catheterized at the First Affiliated Hospital of Nanchang University between November 1, 2005 and February 28, 2017 were included. Patients were divided into diabetes mellitus group (DM group) and non-diabetes mellitus group (NDM group). Outcomes were analyzed by Kaplan-Meier method. Multivariate Cox proportional hazards models were utilized to assess the risk factors of all-cause mortality. Results A total of 977 patients were enrolled. Compared with NDM group, patients in DM group were older (47.5±14.4 vs 59.3±11.3, P＜0.01), had more cardiovascular disease (CVD) (7.5% vs 20.3%, P＜0.01), higher levels of serum hemoglobin (78.2±17.2 vs 82.3±14.6 g/L, P＜0.01) , and lower levels of serum albumin (36.1±5.0 vs 32.7±5.6 g/L, P＜0.01). The one-, three- and five-year patient survival rates of DM and NDM group were 89.7%, 56.0%, 31.9% and 94.7%, 81.3%, 67.4%, respectively.Survival rate was significantly lower in DM group than in NDM group ( χ2=63.51, P＜0.01). Stratified analysis showed that DM group had significant lower survival rate than NDM group in patients younger than 70 years old ( χ2= 73.35, P＜0.01), while survival rate was similar between the two groups patients older than 70 years old ( χ2= 0.003, P=0.96). Multivariate Cox proportional hazards model analysis showed that DM (HR: 1.74, 95%CI: 1.27-2.38, P＜0.01), age (HR: 1.05, 95%CI: 1.04-1.06, P＜0.01), leukocyte (HR: 1.06, 95%CI: 1.00-1.12, P=0.04) and triglyceride (HR: 1.19, 95%CI: 1.07-1.32, P＜0.01) were all independent risk factors for all-cause mortality of PD patients. However, age (HR: 1.05, 95%CI: 1.04-1.07, P＜0.01) and alkaline phosphatase (HR: 1.01, 95%CI: 1.00-1.01, P=0.02) were independent risk factors for all-cause mortality of diabetic patients. Conclusions Long-term survival rate was lower in diabetic PD patients than in non-diabetic PD patients. DM, age, leukocyte and triglyceride were independent risk factors of mortality in PD patients. Age and alkaline phosphatase were independent risk factors of mortality in diabetic patients.     

Prognostic analysis of aged end-stage renal disease patients receiving hemodialysis and peritoneal dialysis

Objective To compare the survival rates of elderly hemodialysis (HD) and peritoneal dialysis (PD) patients and identify their independent prognostic predictors. Methods Patients aging ＞60 years old who initiated dialysis between January 1, 2008 and December 31, 2014 were included. Propensity score method (PSM) was applied to adjust for selection bias. Kaplan-Meier method was used to obtain survival curves and a Cox regression model was used to evaluate risk factors for mortality. Results 447 eligible patients with maintenance dialysis were identified, 236 with hemodialysis and 211 with peritoneal dialysis. 174 pairs of patients were matched, with the baseline data [age, gender, Charlson comorbidity index (CCI) and the primary disease] between two groups showing no significant difference (P＞0.05). Cardiovascular events, cerebrovascular events and infection were major causes of death in both groups and there was no significant difference in the causes of death between two groups (P＞0.05). The overall survival rates at 1 and 5 year were 93.6% and 63.4% respectively in HD group, 91.9% and 61.5% in PD group. The differences of total survival rates between HD and PD patients were not significant (P＞0.05). Cox regression analysis showed age(≥80 year) (P＜0.001, HR=1.058, 95%CI 1.028-1.088), diabetic nephropathy (P=0.001, HR=2.161, 95%CI 1.384-3.373), CCI≥5 (P=0.007, HR=1.935, 95%CI 1.201-3.117) were independent prognostic risk predictors in HD patients; age(≥80 year) (P=0.022, HR=1.043, 95%CI 1.006-1.081), serum albumin level ＜ 35 g/L (P=0.025, HR=1.776, 95%CI 1.075-2.934), and prealbumin (P=0.012, HR=0.968, 95%CI 0.944-0.993) were independent prognostic predictors in PD patients. Conclusions The differences of total survival rates between aged HD and PD patients are not significant. Age, diabetic nephropathy, CCI≥5 and age, serum albumin＜35 g/L, prealbumin＞30 g/L respectively influence the survival of elderly HD and PD patients.     

Mortality and technique failure in patients starting chronic peritoneal dialysis: results of The Netherlands Cooperative Study on the Adequacy of Dialysis. NECOSAD Study Group

BACKGROUND: Recent studies have shown an association between small solute clearance and patient survival. Thus far, little attention has been paid to the potential effects of fluid overload. The aim of this study was to determine the relative importance of baseline patient and treatment characteristics to mortality and technique failure in patients starting peritoneal dialysis. METHODS: One hundred and eighteen consecutive new patients were included in this prospective multicenter cohort study. Cox proportional hazards regression was used to predict mortality and technique failure. RESULTS: There were 33 deaths and 44 technique failures. The two-year patient survival was 77%, and the two-year technique survival was 64%. Age, systolic blood pressure, and the absolute quantity of small solutes removed at baseline were independent predictors of mortality. A one-year increase in age was associated with a relative risk (RR) of death of 1.05 (95% CI, 1.01 to 1.09) and a 10 mm Hg rise in systolic blood pressure, with a RR of 1.42 (95% CI, 1.17 to 1.73). The removal of 1 mmol/week/1.73 m2 of urinary and dialysate creatinine was associated with a RR of death of 0.95 (95% CI, 0.92 to 0.98) and 0.93 (95% CI, 0.89 to 0.98). The removal of urea had a similar association with the RR of death. Predictors for technique failure were urine volume, peritoneal ultrafiltration, and systolic blood pressure. CONCLUSIONS: Dialysate solute removal was an independent predictor of mortality. The association between systolic blood pressure and mortality shows that the maintenance of fluid balance and the removal of small solutes deserve equal attention.     

Higher peritoneal transport status is associated with higher mortality and technique failure in the Australian and New Zealand peritoneal dialysis patient populations

Although early studies observed that peritoneal membrane transport characteristics were determinants of morbidity and mortality in peritoneal dialysis (PD) patients, more recent investigations, such as the Ademex trial, have refuted these findings. The aim of this study was to determine whether baseline peritoneal transport status predicted subsequent survival in Australian and New Zealand PD patients. The study included all adult patients in Australia and New Zealand who commenced PD between April 1, 1999, and March 31, 2004, and had a peritoneal equilibration test (PET) performed within 6 mo of PD commencement. Times to death and death-censored technique failure were examined by Kaplan-Meier analyses and multivariate Cox proportional hazards models. PET measurements were available in 3702 (72%) of the 5170 individuals who began PD treatment in Australia or New Zealand during the study period. In these patients, high transporter status was found to be a significant, independent predictor of death-censored technique failure (adjusted hazard ratio [AHR] 1.23; 95% confidence interval [CI] 1.02 to 1.49; P = 0.03) and mortality (AHR 1.34; 95% CI 1.05 to 1.79, P = 0.02) compared with low-average transport status. High-average transport class was also associated with mortality (AHR 1.21; 95% CI 1.00 to 1.48; P = 0.047) but not death-censored technique failure (AHR 1.04; 95% CI 0.90 to 1.21) compared with low-average transport status. When transport status was alternatively analyzed as a continuous variable, dialysate:plasma creatinine ratio at 4 h was independently predictive of both death-censored technique failure (AHR 1.07; 95% CI 1.01 to 1.295; P = 0.031) and death (AHR 1.09; 95% CI 1.01 to 1.373; P = 0.036 per 0.1 change in dialysate:plasma creatinine). Peritoneal transport rate is a highly significant risk factor for both mortality and death-censored technique failure in the Australian and New Zealand incident PD patient populations.     

Anemia is associated with abdominal aortic aneurysm (AAA) size and decreased long-term survival after endovascular AAA repair

OBJECTIVE: Anemia is a common comorbid condition in various inflammatory states and an established predictor of mortality in patients with chronic heart failure, ischemic heart disease, and end-stage renal disease. The present study of patients with abdominal aortic aneurysm (AAA) undergoing endovascular repair (EVAR) assessed the relationships between baseline hemoglobin concentration and AAA size, as well as anemia and long-term survival. METHODS: Between March 1994 and November 2006, 711 patients (65 women, mean age 75.8 +/- 7.8 years) underwent elective EVAR. Anemia was defined as a hemoglobin level <13 g/dL in men and <12 g/dL in women. Post-EVAR mean follow-up was 48.3 +/- 32.0 months. Association of hemoglobin level with AAA size was assessed with multiple linear regression. Mortality was determined with use of the internet-based Social Security Death Index and the electronic hospital record. Kaplan-Meier survival curves of anemic and nonanemic patient groups were compared by the log-rank method. Multivariable logistic regression models were used to determine the influence of anemia on vital status after EVAR. RESULTS: A total of 218/711 (30.7%) of AAA patients undergoing EVAR had anemia at baseline. After adjustment for various risk factors, hemoglobin level was inversely related to maximum AAA diameter (beta: - .144, 95%-CI: -1.482 - .322, P = .002). Post-EVAR survival was 65.5% at 5 years and 44.4% at 10 years. In long-term follow-up, survival was significantly lower in patients with anemia as compared to patients without anemia (P < .0001 by log-rank). Baseline hemoglobin levels were independently related to long-term mortality in multivariable Cox regression analysis adjusted for various risk factors (adjusted HR: 0.866, 95% CI: .783 to .958, P = .005). Within this model, statin use (adjusted HR: .517, 95% CI: .308 to .868, P = .013) was independently related to long-term survival, whereas baseline AAA diameter (adjusted HR: 1.022, 95% CI: 1.009 to 1.036, P = .001) was an independently associated with increased mortality. CONCLUSIONS: Baseline hemoglobin concentration is independently associated with AAA size and reduced long-term survival following EVAR. Thus, the presence or absence of anemia offers a potential refinement of existing risk stratification instruments.     

替吉奥联合奥沙利铂对比替吉奥联合顺铂治疗晚期胃癌的Meta分析

目的评价替吉奥联合奥沙利铂（SOX方案）对比替吉奥联合顺铂（SP方案）治疗晚期胃癌（AGC）的疗效及安全性。 方法在PubMed、Embase、Web of Science、中国期刊全文数据库（CNKI）、中国生物医学文献数据库（CBM）、万方数据库、维普中文科技期刊数据库中检索2022年7月前公开发表的有关替吉奥联合奥沙利铂（SOX组）对比替吉奥联合顺铂（SP组）治疗AGC的相关研究,按照Cochrane Handbook 5.1的临床试验质量评价标准对文献进行质量评价,采用RevMan 5.4软件进行Meta分析。 结果共有14篇2 650例AGC患者纳入研究,其中SOX组1 334例,SP组1 316例。与SP组比较,SOX组的总生存期（HR=0.87,95% CI：0.78~0.97,P=0.01）、无进展生存期（HR=0.87,95% CI：0.78~0.97,P=0.01）、完全缓解（OR=1.43,95% CI：1.02~2.00,P=0.04）、部分缓解（OR=1.64,95% CI：1.18~2.29,P=0.003）、疾病进展（OR=0.55,95% CI：0.34~0.87,P=0.01）、疾病控制率（OR=1.64,95% CI：1.04~2.56,P=0.03）和疾病稳定（OR=0.67,95% CI：0.53~0.83,P=0.000 4）方面比较,差异均有统计学意义,而两组客观有效率差异无统计学意义（OR=1.57,95% CI：0.85~2.90,P=0.15）。安全性方面,3级及以上不良反应中,SOX组白细胞减少（OR=0.20,95% CI：0.13~0.30,P<0.000 01）、贫血（OR=0.52,95% CI：0.32~0.86,P=0.01）、肌酐升高（OR=0.21,95% CI：0.07~0.61,P=0.004）的发生率更低,而周围感觉神经病（OR=10.64,95% CI：1.85~61.10,P=0.008）的发生率更高。 结论SOX方案可提高AGC的治疗有效率,改善无进展生存期和总生存期,但可能增加周围感觉神经病的发生率。     

Evolution of allograft aortic valve replacement over 13 years: results of 275 procedures.

OBJECTIVE: We describe our center's experience with the use of allografts for aortic valve or root replacement, illustrating the impact on outcome of the changes made in surgical and preservation techniques. METHODS: Between 4/1987 and 1/2001 275 allografts were used in 267 consecutive patients to replace the aortic valve or root. All patients were prospectively followed over time. Mean patient age was 46 years (SD 16; range 0.06-83), male/female ratio was 201/74. Prior cardiac operations took place in 73 patients; 49 patients presented with active endocarditis. Pre-operative NYHA-class was III in 51%. Initially, the subcoronary technique was used (SC; N=95) while in recent years root replacement (ARR; N=180) became the technique of choice. Seven fresh (two pulmonary and five aortic) and 268 cryopreserved (four pulmonary and 264 aortic; 35 glycerol and 233 DMSO) allografts were implanted. Concomitant procedures took place in 133 (48%). RESULTS: Operative mortality was 5.5% (N=15) and during follow-up (99% complete) 29 more patients died. Overall cumulative survival was 73% (95% CI 65-81%) at 9 years postoperative and significantly better for SC compared to ARR patients (P=0.005). Freedom from allograft-related reoperation (N=34) was 77% (95% CI 69-85) at 9 years, and worse in the SC compared to ARR group due to increased early technical failure (P=0.03). Freedom from reoperation for structural valve deterioration (SVD; N=22) was 81% (95% CI 73-89) at 9 years and did not differ between SC and ARR (P=0.51). Independent predictors of degenerative SVD were younger patient age (HR 0.93 with age as continuous variable; 95% CI 0.90-0.97), older donor age (HR 1.06 with age as a continuous variable; 95% CI 1.00-1.11), larger allograft diameter (HR 1.38; 95% CI 1.11-1.71) and the use of pulmonary allografts (HR 10.72; 95% CI 3.88-29.63). Calculated median time to reoperation for structural valve deterioration ranged from 23 years in a 65-year-old patient to 12 years in a 25-year-old. CONCLUSIONS: Aortic valve replacement with allografts yields adequate midterm results. Although important changes have been made over the years to improve durability, allografts still have a limited life span especially in young patients.     

Low total vitamin C plasma level is a risk factor for cardiovascular morbidity and mortality in hemodialysis patients

Hemodialysis patients are prone to deficiency of vitamin C, which constitutes the most abundant nonenzymatic antioxidant in blood. Because antioxidants are involved in the pathogenesis of atherosclerosis, the authors examined the association of total vitamin C plasma level with cardiovascular outcomes in such patients. One hundred thirty-eight consecutive maintenance hemodialysis patients (median age 61 yr, 90 males) were enrolled in a single-center study. At baseline, routine laboratory parameters were recorded, and predialysis total vitamin C plasma levels were measured by high-pressure liquid chromatography. Patients were prospectively followed-up for the occurrence of a primary composite endpoint consisting of fatal and nonfatal major adverse cardiovascular events (MACE) and for all-cause and cardiovascular mortality. MACE occurred in 35 patients (25%) over a period of median 30 mo, and 42 patients (30%) died [29 cardiovascular deaths (21% of total)]. Using Cox proportional hazards modeling, adjusted hazard ratios for the occurrence of MACE were 3.90 (95% confidence interval [CI]: 1.42 to 10.67; P = 0.008) and 3.03 (95% CI: 1.03 to 8.92; P = 0.044) for patients in the lower (<32 micromol/L) and middle (32 to 60 micromol/L) tertile of total vitamin C levels, compared with patients in the upper tertile (>60 micromol/L). Hazard ratios for cardiovascular death were 3.79 (95% CI: 1.23 to 11.66; P = 0.020) and 2.89 (95% CI: 0.89 to 9.37; P = 0.076). Total vitamin C levels were not independently associated with all-cause mortality. This study concludes that low total vitamin C plasma levels predict adverse cardiovascular outcomes among maintenance hemodialysis patients. Future studies should address the potential protective effect of an adequate vitamin C supplementation.     

Impact of immunosuppressive regimen on survival of kidney transplant recipients with hepatitis C

BACKGROUND: Hepatitis C virus (HCV) infection is common among end-stage renal disease patients receiving hemodialysis and a kidney transplant. HCV-positive kidney transplant recipients have worse clinical outcomes than those who are HCV negative. The optimal immunosuppressive regimen in this group of patients remains uncertain. METHODS: Using data obtained from the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients, we studied the impact of induction and maintenance immunosuppression on risk of patient death, with death-censored graft failure and death with a functioning graft as secondary endpoints. Cox regression analysis was used to estimate hazard ratios (HR) adjusted for donor, recipient, and transplant variables. A total of 3708 HCV-positive and 75,629 HCV-negative kidney transplant recipients were analyzed. RESULTS: Patient survival was negatively affected by HCV-positive serology. Among HCV-positive kidney transplant recipients, a reduced HR for patient death was observed with the use of induction therapy (HR=0.75, 95% CI 0.61-0.90, P=0.003) and with the use of mycophenolate mofetil (HR=0.77, 95% CI 0.64-0.92, P=0.005). CONCLUSIONS: In kidney transplant recipients with HCV-positive serology, the use of antibody induction did not negatively affect patient survival and the use of mycophenolate mofetil as part of maintenance immunosuppression was associated with better patient survival.     

Preemptive versus Non-preemptive simultaneous pancreas-kidney transplantation: a single-center, long-term, follow-up study

BACKGROUND: Data regarding the timing-before or after initiation of dialysis-of simultaneous pancreas-kidney transplantation (SPKT) in type 1 diabetes mellitus patients with end-stage renal failure are sparse. We studied the effect of preemptive transplantation on patient survival, cardiovascular endpoints, and graft survival, as compared with non-preemptive transplantation. METHODS: All 180 SPKT recipients (aged 23-58 years) who received a SPKT in Leiden between December 1986 and May 2004 were included in the analysis. Sixty-five patients (36.1%) were transplanted preemptively. Mean follow-up time was 6.3 years. RESULTS: Up to 8.2 years after transplantation, we found no differences in patient survival. Later on, divergence occurred: 10-year patient survival was 71.3% in the preemptive group versus 63.8% in the dialysis group and 15-year patient survival was 64.8% versus 45.1% in the dialysis group, leading to an adjusted hazard ratio for mortality of 0.50 (95% CI 0.23-1.06, P=0.070). Cause of death was less often of cardiac origin in the preemptive group (adjusted HR 0.16; 95% CI 0.026-0.95, P=0.044). Graft survival did not follow the same trend. No significant differences were found between the two groups considering allograft survival, cerebrovascular accident, or myocardial infarction. The percentage of patients with minor or major amputation(s) after transplantation was slightly lower in the preemptive group (24.6 vs. 32.1%; adjusted HR 0.87; 95% CI 0.42-1.82, P=0.72). CONCLUSION: Preemptive SPKT offered a patient survival benefit as compared with transplantation performed while already on dialysis and was associated with a lower rate of cardiac deaths.     

Increased risk of modality failure with higher serum uric acid level in continuous ambulatory peritoneal dialysis patients: a prospective cohort study

BackgroundPeritoneal dialysis (PD) is one of the most important kidney replacement therapies for patients with end‐stage kidney disease (ESKD). PD technique failure can lead to an escalated cost and increased infectious and cardiovascular risk, up and including to death. The accumulation of uric acid (UA) was associated with adverse outcomes in ESKD patients. However, the relationship between serum UA and technique failure is little explored.MethodsHere, a total of 266 continuous ambulatory peritoneal dialysis (CAPD) patients (age, 41.8 ± 12.6 years; 125 males) were enrolled and followed up for 31.7 months. Serum UA levels were examined at baseline and each visit. Subjects were divided into three groups according to their baseline serum UA concentrations. Multivariable Cox regression models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of PD technique failure.ResultsThe level of serum UA increased gradually as time prolonged. During the follow-up period, 77 (28.9%) patients occurred PD technique failure, of which 56 (21.1%) transferred to hemodialysis (HD) and 21 (7.9%) died. Compared to the lowest UA tertile, after adjusting for potential confounders, HRs of technique failure in tertile 2 and tertile 3 were 1.82 (95% CI: 0.95–3.49) and 2.03 (95% CI: 1.05–3.92), respectively, and p for trend was 0.043. Adjusted HRs of all-cause technique failure, transferring to HD and mortality with each 1 mg/dL increase in serum UA were 1.20 (95% CI: 1.03–1.40, p = 0.019), 1.22 (95% CI: 1.01–1.48, p = 0.039), and 1.25 (95% CI: 0.94–1.67, p = 0.128), respectively.ConclusionHigher serum UA level predicted higher risk of technique failure in CAPD patients.     

Patient and technique survival of diabetics on peritoneal dialysis: one-center's experience and review of the literature

BACKGROUND: Diabetes is the leading cause of end-stage renal disease (ESRD). This retrospective study investigated the long-term patient and technique survival and sought to identify the predictors of mortality in diabetic patients receiving PD. METHODS: Patients, aged 17 years or more who commenced home PD between January 31, 1994, and December 31, 2001 were included. Clinical data were available for 358 patients out of 418 total patients who started PD during this period. They were followed until cessation of PD, death, or to January 31, 2003. Survival probabilities were generated according to the Kaplan-Meier method, and multivariate Cox proportional hazards models were used to assess predictors of survival. RESULTS: A total of 358 patients were enrolled in the study. Among them, 139 patients (38.8%) were diabetics. The 1-, 2-, 3- and 5-year patient survival rates were 91%, 76%, 66% and 47% in diabetics and 94%, 89%, 84% and 69% in non-diabetics, respectively. Median actuarial patient survival for diabetic patients (51.8 months; 95% CI 36.0 a 67.5 months) was significantly shorter than that of non-diabetic patients (log rank 14.117, p < 0.001). Death-censored technique survival rates at 1-, 2-, 3- and 5-year were 90%, 83%, 67% and 58% in diabetic, and 94%, 87%, 77% and 70% in non-diabetic patients, respectively. Similar to patient survival, the median technique survival time was significantly shorter for diabetic patients (63.9 months; 95% CI 35.7 - 92.2 months) than that of non-diabetic patients (log rank 4.884, p = 0.027). Multivariate Cox regression analysis showed that advancing age was the only independent predictor of death in the diabetic patients, whereas higher age and wider pulse pressure were associated with mortality in non-diabetic patients. CONCLUSION: Long-term patient and technique survival for diabetic patients on PD seem to be improved compared to our previous report and other studies. The mortality of diabetic patients was predicted predominantly by advancing age. PD remains a viable form of long-term renal replacement therapy for diabetic patients with ESRD.