Patient and technique survival in continuous ambulatory peritoneal dialysis (CAPD) with a basic three 2-liter daily exchanges: a 12- year single center experience in the pre-urea kinetics era

Continuous ambulatory peritoneal dialysis (CAPD) is the prevailing mode of renal replacement therapy in Hong Kong and the routine practice is three 2 L daily exchanges with four exchanges reserved for patients with ultrafiltration problems or clinically inadequate dialysis. In our hospital, Tung Wah Hospital, adequacy of dialysis assessment by urea kinetics was conducted after 1993 and adjustment of dialysis regime according to Kt/V was made only after 1995. This study represented the survival data of CAPD patients in our center before the urea kinetics era. From 1983 to 1994, we have accepted 569 patients into our CAPD program with a mean age ±SD of 47.8 ±15.4 and incidence of diabetes of 17.9%. The overall patient survival rates were 92%, 56% and 26% at 1, 5 and 10 years respectively. The corresponding technique survival rates were 97%, 86% and 60%. A cross-sectional analysis of the CAPD population from 1993 to 1994 showed that only 5% of patients were on four 2 L exchanges and the mean Kt/V was 1.76 ±0.35 and creatinine clearance 58.1 ±23.2 L/week/1.73 m². The patient and technique survival rates were comparable to western centers with a higher mean Kt/V and creatinine clearance. Our data showed that favorable clinical outcome can be achieved with three 2 L daily exchange regime in Chinese patients. This indicates different Kt/V standards may exist for different racial populations.     

The effect of cyclosporine on native renal function in non-uremic diabetic recipients of pancreas transplants

In order to assess the nephrotoxic effect of cyclosporine on native kidneys in pancreas transplant recipients, serum creatinine and creatinine clearance levels were determined before and serially after pancreas transplantation alone in 33 non-uremic Type I diabetic patients. The mean serum creatinine level before transplant was 1.0±0.3 mg/dl, and the values at 2 weeks, 6 months, 1 to 2 years, and > 2 years after transplant were, respectively, 1.5±0.6, 1.4±0.4, 1.4±0.5, and 1.5±0.2 mg/dl. Mean creatinine clearance level before transplant was 90±34 ml/min, and the values and the corresponding time points were 55±23, 62±22, 58±13, and 63±16. Thus, the mean changes in both parameters were approximately 50% in the immediate period after transplant, and there was no additional deterioration by these measures of renal function. The changes were somewhat greater than those reported in newly diagnosed diabetic patients receiving cyclosporine for immunotherapy, but all of the subjects had histologic evidence of diabetic nephropathy at the time of transplant. Although the stabilization of renal function is encouraging, damage to the kidneys may be silent and serial renal biopsies are needed to allow full assessment of the impact of cyclosporine on renal pathologic conditions.     

Continuous ambulatory peritoneal dialysis. Eight years of experience at a single center

One hundred and thirty-four patients using continuous ambulatory peritoneal dialysis (CAPD) for a mean time of 23.1 +/- 18.3 months (range, 1-76.6) from a single center are reviewed with respect to biochemistry, hematology, parameters of dialysis efficiency, nutrition, and the nature and frequency of complications. Cumulative patient survival was 90%, 86% and 75% at 1, 2 and 3 years, and survival of patients using this technique was 75%, 62% and 40% at corresponding time intervals with no difference demonstrated in diabetic patients or in those older than 50 years. Biochemical and hematologic parameters were well maintained with peritoneal creatinine clearance increasing and peritoneal protein loss remaining stable with ongoing CAPD. Loss of ultrafiltration, however, accounted for 17.7% of permanent transfers to alternative therapy. Low serum albumin and elevated serum triglyceride concentrations correlated with mortality, whereas low serum albumin, low cholesterol, and high phosphate levels correlated with morbidity as assessed by frequency of hospital admissions. Dietary protein intake assessed by urea generation rate was significantly lower than that estimated from a 24-hour dietary recall (0.82 vs. 1.02 g/kg/day, p less than 0.01) and with the exception of body mass index and serum albumin, anthropometric and visceral protein measurements showed few correlations with nutritional adequacy. Bacterial peritonitis remained the major complication, although fungal infections made a significant contribution to morbidity and mortality. Overall, CAPD is confirmed to be a satisfactory form of dialysis for all forms of end-stage renal failure and an integral part of any renal replacement program. However, nutritional adequacy and lowering of complication rates require further investigation.     

Normalization of hematocrit in patients with end-stage renal disease on continuous ambulatory peritoneal dialysis: The role of erythropoietin

Observations were made retrospectively and prospectively over one year on all patients on continuous ambulatory peritoneal dialysis (CAPD) to determine the effect of this modality on the hematocrit. Serum erythropoietin and parathyroid hormone levels were measured. Within five months the hematocrit increased 47 to 127 percent up to normal in four of nine patients. Five others remained severely anemic. There was no significant difference in serum creatinine levels among the patients within one month of CAPD. The four patients who responded were anemic while on hemodialysis and other modalities of end-stage renal disease management prior to CAPD. The serum erythropoietin level in the four patients who responded was 9.0 mU/ml or greater with a mean of 28 mU/ml, whereas in those who did not respond it was 5.0 mU/ml or less with a mean of 3 mU/ml. Since uremic toxins in the middle molecule range have been postulated to be responsible for erythropoiesis suppression in end-stage renal disease, and in addition, insufficient erythropoietin production and the clearance of some middle molecular weight substances is six times greater with CAPD than with hemodialysis, it appears that CAPD can normalize the hematocrit in patients with end-stage renal disease who were anemic on other modalities with little or no change in serum creatinine, provided the remnant kidneys are capable of producing sufficient erythropoietin. Parathyroid hormone levels were higher in patients who responded than in patients who did not respond.     

Exercise regimen for patients with diabetic nephropathy

To elucidate the relationship between physical activity and the progress of diabetic nephropathy, patients were divided into two groups with physical activity maintained (G) or restricted (R). The period between the onset of 1+ and 3+ proteinuria was 56 ± 25 months in G and 68 ± 25 months in R. But the period between 3+ proteinuria and the serum creatinine exceeding 2.0 mg/dl was 29 ± 19 and 23 ± 22 months, respectively. Duration of the nephrotic stage before the entry to dialysis was about 27 months in each group. After initiation of hemodialysis or continuous ambulatory peritoneal dyalysis (CAPD), postural hypotension tended to be less in G and Karnofsky score for fitness in daily physical activity was significantly better in G. Even after macroalbuminuria emerged, it was concluded that a strict restriction of exercise is of little benefit.     

Difficulty in Improving Malnutrition and Low‐grade Inflammation in Diabetic Patients on Peritoneal Dialysis

Continuous ambulatory peritoneal dialysis (CAPD) is commonly used for renal replacement therapy in diabetes mellitus (DM) patients. We investigated the changes of peritoneal transport characteristics, nutritional status, and adequacy and inflammation parameters in diabetic CAPD patients (N = 17) compared to non‐diabetic patients (N = 23). Peritoneal equilibrium testing, nutritional, biochemical, and anthropometric parameters and adequacy were prospectively assessed at 1 (baseline), 6 and 12 months after initiating CAPD. The levels of several nutritional parameters were lower and did not change in DM patients over time (P < 0.05) and significantly improved in the non‐DM patients over time (P < 0.05). Total weekly creatinine clearance and residual renal function exhibited a rapid decline (P < 0.05) and inflammation parameter levels were higher in DM patients (P < 0.05). Our results showed the difficulty in improvement of nutritional status and inflammatory parameters in diabetic patients during at least the first year of CAPD compared to non‐DM patients.     

Decreased insulin requirement in relation to GFR in nephropathic Type 1 and insulin-treated Type 2 diabetic patients.

AIMS: In the presence of impaired renal function, patients require less insulin mainly because insulin clearance is prolonged. The aim of this study was to evaluate the insulin requirement related to glomerular filtration rate (GFR) in nephropathic Type 1 and Type 2 diabetic patients. METHODS: In a retrospective study we compared insulin requirement in 20 nephropathic Type 1 diabetic patients and 20 insulin-treated Type 2 diabetic patients from the onset of overt nephropathy until the final stage of renal disease. All patients had proteinuria > 0.5 g/24 h and creatinine clearance >/= 80 ml/min per 1.73 m2 at baseline. Creatinine clearance, urinary protein excretion, glycated haemoglobin and the required insulin doses were determined 3- to 6-monthly, basal C-peptide was measured at the beginning and the end of the observation period. The required insulin doses were evaluated at creatinine clearance rates of 80, 60, 40, 20 and 10 ml/min per 1.73 m2 (or at the initiation of dialysis treatment). RESULTS: The insulin requirement of patients with Type 1 diabetes was reduced from 0.72 +/- 0.16 IU/kg per day at a creatinine clearance rate of 80 ml/min, to 0.45 +/- 0.13 IU/kg per day at a creatinine clearance rate of 10 ml/min (decrement of 38%, P < 0.001). The insulin dose required by Type 2 diabetic patients was reduced from 0.68 +/- 0.28 IU/kg per day at a creatinine clearance rate of 80 ml/min to 0.33 +/- 0.19 IU/kg per day at a clearance rate of 10 ml/min (decrement 51%, P < 0.001). The fall in GFR, urinary protein excretion and glycated haemoglobin levels was similar in the two groups. In patients with Type 2 diabetes, C-peptide levels at the beginning and the end of renal function impairment were 2.2 (0.4-7.3) vs. 2.7 (0.1-4.9) ng/ml (NS). The reduction in insulin requirement was approximately the same in patients with an initial C-peptide level < 1.0 and in those >/= 1.0 ng/ml (decrement 57% vs. 46%). CONCLUSIONS: The reduction in insulin requirement in renal insufficiency is similar in Type 1 and insulin-treated Type 2 diabetic patients. In subjects with Type 2 diabetes, the residual insulin secretion has no impact on the reduction in insulin requirement dependent on the GFR.     

Continuous ambulatory peritoneal dialysis (CAPD) in patients with diabetic nephropathy

A 3-centre study was done to analyse the results of 70 patients with end-stage renal disease caused by diabetic nephropathy and treated with CAPD. Fifty patients had insulin-dependent diabetes (mean age 42, mean duration of diabetes 24 yr); 20 had non-insulin-dependent diabetes (mean age 61, mean duration 15 yr). Total treatment time was 1563 months and ranged from one to 83 months (median 18). Patient survival was 86% at 1 yr and 33% at 4 yr. Technique survival was 87% and 63%. Cox's multiple hazard regression analysis showed that age above 45 yr (relative risk 2.2), systolic hypertension (2.6) and cardiac disease (2.2) at the start of CAPD were associated with shorter patient survival. Metabolic control was good. Haemoglobin rose during the first 3 months. Plasma creatinine concentration increased with time, probably due to the loss of residual renal function. HbA1c levels were in the normal range for 60% of the patients. Mean hospital stay was 42 days per year, 26 as a consequence of vascular complications and 16 due to peritonitis and catheter-related problems. We conclude that CAPD is a good renal replacement modality for patients with diabetic renal failure. The patient survival is dependent on age, systolic hypertension and cardiac disease at the start of CAPD.     

Treatment of end-stage diabetic nephropathy: over a decade of experience at one institution

Results of treatment of end-stage renal disease in 139 patients with diabetes mellitus revealed survival of 76% at 1 year and 48% at 5 years. These results compare favorably with other reports from Europe and the United States, probably because of the greater number of patients receiving renal transplants, and possibly because of the use of continuous ambulatory peritoneal dialysis as a recent treatment modality. Patients not receiving transplants were much older (mean age, 47.8 years) than those receiving transplants. Of those not given transplants, survival was best on CAPD. Comparison of those surviving at least 3 years was made with those expiring in the first year. Long-term survivors were younger, had diabetes for a shorter period, but had higher mean blood pressures and serum creatinine values than short-term survivors. Short-term survivors also had over a 50% incidence of prior myocardial infarction or cardiorespiratory arrest, while no long-term survivors had such a history. Long-term survivors were also more likely to have received a transplant, and short-term survivors were more likely to have received intermittent peritoneal dialysis or hemodialysis. A transplant from a living related donor is the treatment of choice for diabetics under age 40 and perhaps for older patients as well. The choice among CAPD, hemodialysis and cadaver transplant requires consideration of many factors.     

Overview of Regular Dialysis Treatment in Japan as of 31 December 2006

A statistical survey of dialysis patients for the year 2006 was carried out for 4051 medical facilities across Japan, and responses were received from 3985 (98.37%) facilities. There were 264 473 dialysis patients (including 9003 peritoneal dialysis patients) in Japan at the end of 2006, which showed an increase of 6708 (2.6%) from the end of 2005. The number of patients per million population was 2069.9. The crude mortality rate during 2006 was 9.2%. The mean age of the patients who began dialysis (in 2006) was 66.4 years, and the mean age of the entire dialysis population was 64.4 years. The primary renal diseases of the patients who began dialysis were diabetic nephropathy (42.9%), chronic glomerulonephritis (25.6%), and nephrosclerosis (9.4%). Of the 3488 facilities that participated in the survey on the dialysate water quality, 2873 facilities (82.4%) measured the endotoxin concentration in the dialysate; and 1197 facilities (37.1%) out of 3228 measured the bacterial count in the dialysate. The mean hemoglobin concentration in the dialysis population at the end of 2006 was 10.23 ± 1.33 g/dL, which was equal to that at the end of 2005 (10.23 ± 1.37 g/dL). The mean concentration of serum creatinine in 15 853 patients who started dialysis during 2006 was 8.37 ± 3.58 mg/dL. The estimated glomerular filtration rate, which was calculated with formula modified for the Japanese population from the Modification of Diet in Renal Disease (MDRD) Study equation, was 5.46 ± 6.60 mL/min/1.73 m².     

Effect of insulin on renal sodium handling and renal haemodynamics in insulin-dependent (type 1) diabetes mellitus patients

The effects of insulin on renal haemodynamics and renal sodium handling were studied in eight insulindependent (type 1) diabetic patients (aged 30±3 years). Seven healthy men (aged 38±4 years) served as controls. The type 1 diabetic patients were resistant to insulin-stimulated glucose disposal as estimated by a 45% lower metabolic (P<0.01) clearance of glucose as compared with controls. However, type 1 diabetic patients were still sensitive to the distal tubular antinatriuretic effect of insulin, as indicated by an increase in distal sodium reabsorption (95.5%±0.5% to 96.9%±0.4%;P<0.05) during insulin infusion compared with controls (95.5%±0.6% to 97.4%±0.3%;P<0.05). In control subjects insulin infusion was associated with 9% increases (P<0.05) in lithium clearance and in renal plasma flow, whereas no significant increases in lithium clearance and in renal plasma flow were observed in the type 1 diabetic patients. In both groups, the changes in renal plasma flow in response to insulin infusion were positively correlated with that in lithium clearance (r=0.80 andr=0.90, respectively;P<0.05?0.01). In conclusion, the present result demonstrates an intact distal tubular sodium retaining effect in conjunction with a blunted decrease in proximal tubular sodium reabsorption following insulin infusion, which could be the result of an impaired renal vasodilation in type 1 diabetes mellitus.     

End-stage renal disease and dialysis in hereditary amyloidosis TTR V30M: presentation,survival and prognostic factors

Classical familial amyloid polyneuropathy may have a course with progressive renal impairment. We studied 62 patients (24 males, 38 females) with FAP, transthyretin variant V30M, and end-stage renal disease (ESRD) treated with hemodialysis, all referred to a single center over a period of 11 years. Clinical course, morbidity and survival after dialysis were analyzed. Patient's mean age at first dialysis was 51.5?±?10.7 years, and mean duration of neuropathy was 10.2?±?3.8 years. The most frequent form of presentation of FAP nephropathy was nephrotic proteinuria with renal dysfunction. In the year prior to dialysis, renal function declined rapidly, and fluid overload was the main indication to initiate treatment. The presence of decubitus ulcers, significant disability, venous catheter for definitive vascular access for long-term treatment, and permanent bladder catheter, were related to death during the first year of dialysis. The mean duration of renal replacement therapy was 21 months, with a 54.5% one year, and 38.4% two year treatment survival. However, when the duration of neurological symptoms at first dialysis exceeded 10 years, survival was significantly lower. Infections, (41% were decubitus ulcers with sepsis) were the cause of early, as well as late mortality. Early creation of vascular access for hemodialysis, surveillance of skin wounds, and intervention on neurogenic bladder are essential to improve the prognosis of ESRD in FAP.     

Peritoneal Protein Losses Depend on More Than Just Peritoneal Dialysis Modality and Peritoneal Membrane Transporter Status

Peritoneal protein clearance (PPCl) depends upon vascular supply and size selective permeability. Some previous reports suggested PPCl can distinguish fast peritoneal membrane transport due to local or systemic inflammation. However, as studies have been discordant, we wished to determine factors associated with an increased PPCl. Consecutive patients starting peritoneal dialysis (PD) who were peritonitis-free were studied. Data included a baseline peritoneal equilibration test (PET), measurement of dialysis adequacy, 24-h dialysate PPCl and body composition measured by multifrequency bioimpedance. 411 patients, mean age 57.2 ± 16.6 years, 60.8% male, 39.4% diabetic, 20.2% treated by continuous ambulatory peritoneal dialysis (CAPD) were studied. Mean PET 4-h Dialysate/Serum creatinine was 0.73 ± 0.13, with daily peritoneal protein loss 4.6 (3.3–6.4) g, and median PPCl 69.6 (49.1–99.6) mL/day. On multivariate analysis, PPCl was most strongly associated with CAPD (β 0.25, P < 0.001), extracellular water (ECW)/total body water (TBW) ratio (β 0.21, P < 0.001), skeletal muscle mass index (β 0.21, P < 0.001), log N-terminal brain natriuretic peptide (NT-proBNP) (β 0.17, P = 0.001), faster PET transport (β 0.15, P = 0.005), and normalized nitrogen appearance rate (β 0.13, P = 0.008). In addition to the longer dwell times of CAPD, greater peritoneal creatinine clearance and faster PET transporter status, we observed an association between increased PPCl and ECW expansion, increased NT-proBNP, estimated dietary protein intake and muscle mass, suggesting a link to sodium intake and sodium balance, increasing both ECW and conduit artery hydrostatic pressure resulting in greater vascular protein permeability. This latter association may explain reports linking PPCl to patient mortality.     

Effect of long-term near-normoglycemia on the progression of diabetic nephropathy

The effect of prolonged restoration of near-normoglycemia on the progression of diabetic nephropathy was evaluated in a controlled study in which 10 insulin-dependent (type 1) diabetic patients with clinical proteinuria were randomized to continue with conventional insulin treatment (CIT) or to undertake more intensive diabetic therapy using continuous subcutaneous insulin infusion (CSII). The patients, mean age 33 +/- 8 yr, mean duration of diabetes 15 +/- 4 yr, were studied before and during 12 months of either CIT or CSII therapy. Glycemic control was assessed by means of mean blood glucose (MBG) +/- Standard deviation (SD), urinary glucose excretion and glycosylated hemoglobin, while renal function was assessed by albumin, IgG and beta-2-microglobulin urinary excretion rates, serum creatinine and creatinine clearance. Blood glucose level, urinary glucose excretion and glycosylated hemoglobin fell significantly in the CSII group, while no differences were found in the CIT group after the 12 months observation period. Both groups showed a deterioration in all indices of renal function, as illustrated by an increase of protein excretion rates and of serum creatinine, and by a decline in creatinine clearance. Comparison of the rate of increase of urinary albumin and IgG excretion and of serum creatinine and of the rate of fall in creatinine clearance between CIT and CSII groups demonstrated that the rate of progression of diabetic nephropathy may be slowed by correction of hyperglycemia. Our study, with due reservations because of the small number of examined patients and differences in kidney function at the beginning of the trial shows that intensive diabetic care may play a role in the proteinuric stage of diabetes in slowing further destruction of residual glomerular structure and in delaying end stage renal failure.     

Antiproteinuric Effect of an N-Type Calcium Channel Blocker,Cilnidipine

The objective of the present study was to determine antiproteinuric effect of an N-type calcium channel blocker—cilnidipine. Subjects were 43 essential or renal hypertensive subjects who had been taking calcium channel blockers other than cilnidipine for at least 6 months. All patients had proteinuria greater than 0.2 g/day in spite of fair blood pressure control (< 150/90 mmHg). Calcium channel blockers in 25 patients (62 ± 3 years) were switched to cilnidipine (cilnidipine group), whereas other 18 patients (58 ± 3 years) continued to take originally prescribed calcium channel blockers (control group). The 24-hr urine collections were done at baseline and after 6 months of the follow-up period. Baseline characteristics including age, blood pressure levels, body mass index and creatinine clearance were similar between cilnidipine and control groups. Urinary protein excretion also was comparable between cilnidipine (0.61 ± 0.10 g/day) and control (0.86 ± 0.17 g/day) groups. Urinary protein significantly decreased after 6 months in cilnidipine group (? 0.21 ± 0.11 g/day, ? 36%, p < 0.01), whereas it did not change in control group (+ 0.01 ± 0.15 g/day, 0.4%, ns). There were no significant changes in blood pressure, serum creatinine, creatinine clearance, estimated protein intake, and urinary salt excretion during the follow-up period in either group. The reduction of urinary protein by cilnidipine was evident in essential hypertensives (? 54 ± 9%, n = 18, p < 0.01) but not in renal hypertensives (+ 10 ± 35%, n = 7, ns). Results suggest that cilnidipine has an antiproteinuric effect especially in patients with essential hypertension.     

The treatment of diabetic renal failure by continuous ambulatory peritoneal dialysis

During the 6-year period 1981-1987, 309 patients started chronic ambulatory peritoneal dialysis (CAPD), of whom 75 (24%) had diabetes. Despite severe peripheral vascular problems (20%), ischaemic heart disease (90%), and complete blindness (21%) the 1-year patient survival on CAPD was 88%. The actuarial patient survival for diabetic patients was similar to that of the non-diabetic cohort over the first 18 months but fell to 48% (compared to 70% in non-diabetic patients) at 3 years. Complications associated with CAPD, including the incidence of peritonitis, were no different between the diabetic and non-diabetic patient populations. Successful treatment for end-stage renal disease (ESRD) in diabetic patients can be achieved and justified in a liberal selection programme for the treatment of diabetic ESRD.     

The progression of diabetic nephropathy in type I diabetics: Relationship to metabolic control and blood pressure

This study was designed to investigate the importance of risk factors such as hyperglycemia and elevated systolic and diastolic blood pressures on the progression of renal insufficiency in diabetics suffering from diabetic nephropathy. Seventeen patients with Type I, insulin-dependent diabetes mellitus (IDDM) (8 women and 9 men) undergoing chronic hemodialysis were investigated by retrospective follow-up and compared with 17 age and sex matched IDDM patients without diabetic nephropathy (controls). According to the time interval of creatinine increase from 200 to 600 μmol/I, the patients were divided arbitrarily into two groups with rapidly (group I<20 months) or slowly progressive (group II≥20 months) renal insufficiency. This period was 13.4±2.05 months in group I (age 36.67±2.47 years, diabetes duration 23.55±2.37 years) and 32.75±4.34 months in group II (age 40.62±2.63 years, diabetes duration 26.62±2.63 years, P.n.s.), respectively. The IDDM patients studied exhibited individually differing progressions of renal insufficiency at different times after manifestation of diabetes. After 15 years of diabetes duration, both risk factors, that is blood pressure and blood glucose concentrations, were elevated in nephropathic diabetics when compared with controls (p<0.01). During the phase of declining kidney function, mean blood pressures were found to be higher in IDDM patients with rapid progression of renal insufficiency when compared with slowly progressing diabetics. Although both risk factors were related to diabetic nephropathy, during the phase of renal insufficiency hypertension appeared to be more closely related to the further deterioration of kidney function.     

Peritoneal dialysis in the nineth decade of life experience in a single center

The clinical outcome of 21 patients on CAPD who were older than 79 years at the time of beginning dialysis is reported in the present paper. These patients represented 5% of 420 patients who were admitted to the CAPD program of our Unit between 1980 and 1995. Fifteen of the patients were men and 6 women, with a mean age of 81 ± 3 years. The median patient survival was 21 months, after 3 years patient survival rate was 30%. The causes of death were cardiovascular (7), cachexia (4), peritonitis (1), liver failure (1) and withdrawal of dialysis (2). The peritonitis rate was 0.6 episodes/year, 45% of episodes were caused by gram + bacteria, 23% by gram - bacteria and in the other episodes peritoneal fluid culture was not performed or no growth was observed. Exit site infection rate was 1 episode every 32 months. Three peritoneal catheters were removed after 1, 14, and 23 months. Most severe complications were dementia (5) and depression (4), severe peripheral vascular disease with pain and ulcers in 3 cases. Quality of life was poor in 4/11 patients surviving after one year. Sixteen patients required a partner for performing the exchanges and many of them needed frequent hospitalization or equivalent care at home.     

Follow-up of 91 living-related renal allograft donors

The long-term risks of uninephrectomy in the living-related kidney donors are of concern. We studied the outcome in living-related allograft donors after donation who have been followed up at Princess Margaret Hospital from 1980 to 1996 by comparing renal function, blood pressure and proteinuria.Ninety-one allograft donors, aged from 19 to 59 years (mean 36.61 ±7.63 years; 43 males and 48 females) were followed up for 1 to 17 years (mean 5.5 ±2.5 years). After nephrectomy, serum creatinine rose by 46.2% from baseline 81.3 ±13.0 μmol/L to 118.9 ±32.9 μmol/L at 3 months (p < 0.001). In 58 of the 91 patients who were followed up for more than 3 years, serum creatinine decreased to 99.7 ±13.2 μmol/L (p < 0.05) at the end of the study period as compared with serum creatinine at 3-month follow-up. Creatinine clearance also decreased from 107.6 ±24.0 ml/min before nephrectomy to 78.8 ±15.7 ml/min at 1-year follow-up (p < 0.001). Then it became 79.8 ±18.3 ml/min at the latest follow-up (p = 0.599). Systolic blood pressure increased from 114.2 ±8.6 mmHg before nephrectomy to 120.0 ±10.4 mmHg (p < 0.001) at the latest follow-up after nephrectomy. Meanwhile, the diastolic blood pressure rose from 71.1 ±7.2 mmHg at baseline to 73.1 ±8.3 mmHg at the end of the study period (p = 0.091). The mean arterial blood pressure increased from 85.5 ±7.0 mmHg to 88.7 ±8.1 mmHg at the latest follow-up (p > 0.005). Proteinuria increased from 65 ±55 mg/day to 96 ±55 mg/day at the latest follow-up (p = 0.142).In conclusion, there was no progression of renal dysfunction in renal allograft donor after nephrectomy. Serum creatinine even improved significantly at the end of the study period as compared with that at 3-month postnephrectomy. Systolic blood pressure and mean arterial blood pressure had a small increment at the latest follow-up. The prevalence of hypertension was 4.4%. Moreover, proteinuria did not show a significant increase after donation.     

Radioiodine dosimetry in patients with end-stage renal disease receiving continuous ambulatory peritoneal dialysis therapy

In patients with end-stage renal disease (ESRD), Na131I dosages for thyroid cancer may have to be reduced to avoid excess radiation doses to red marrow, because radioiodine is primarily excreted by kidneys. In ESRD patients receiving continuous ambulatory peritoneal dialysis (CAPD) therapy (three to five 2-L exchanges daily) creatinine clearance rates are very low (mean, 7 mL/min), and radioiodine clearance rates may be proportionately reduced. Thus, radioiodine kinetic studies were performed in two hypothyroid CAPD patients with thyroid cancer, in eight euthyroid CAPD patients, and in eight thyroid cancer patients with normal renal function. All received Na131I or Na123I orally, with serial blood, urine, and/or dialysate sampling for 24-70 h. Dosimetry calculations were performed using the MIRDOSE3 computer program. In CAPD patients, serum radioiodine half-times were 5 times longer, and radioiodine clearance rates by urine plus dialysate were 20% of those in patients with normal renal function. Na131I dosages for the two CAPD patients with thyroid cancer were reduced from 150 mCi [5.6 gigabecquerels (GBq)] to 26.6 mCi (0.98 GBq) and 29.9 mCi (1.11 GBq), respectively, resulting in radiation doses to red marrow and total body comparable to those in patients with normal renal function who received a mean of 148 mCi (5.5 GBq) Na131I. Thus, in patients receiving continuous ambulatory peritoneal dialysis therapy, 5-fold reductions in radioiodine clearance rates require 5-fold decreases in Na131I dosages to avoid excessive radiation doses to total body and red marrow.