Association of serum magnesium with cardiovascular mortality and all-cause mortality in peritoneal dialysis patients

Objective To investigate the association of serum magnesium with cardiovascular disease (CVD) and all-cause mortality in peritoneal dialysis patients. Methods A retrospective study was performed in patients who initiated peritoneal dialysis from January 1, 2013 to July 31, 2019 in the Shaoxing People's Hospital. According to the standard of serum magnesium, the patients were divided into control group (Mg≥0.7 mmol/L) and low-magnesium group (Mg﹤0.7 mmol/L). The differences in baseline biochemical variables, comorbidities, medications, and clinical outcomes between the two groups were compared. Logistic regression was used to analyze the related factors of hypomagnesemia. Kaplan-Meier survival analysis and Fine-Gray model were used to compare the difference in cumulative survival rate between the two groups. Cox regression model and competitive risk model were used to analyze the risk factors of all-cause mortality and CVD mortality. Results A total of 381 peritoneal dialysis patients were enrolled in this study. Among them, 321 patients were in control group and 60 patients in low-magnesium group. The total median follow-up time was 27(15, 43) months. There were significant differences in serum albumin, magnesium, phosphorus, intact parathyroid hormone, low-density lipoprotein chloesterol, high sensitivity C-reactive protein and 4-hour dialysate-to-plasma creatinine (4 h D/Pcr) between the two groups. CVD was the main cause of death in patients on peritoneal dialysis. Multivariate logistic regression analysis showed that hypoalbuminemia (OR=0.901, 95%CI 0.831-0.976, P=0.011), hypophosphatemia (OR=0.217, 95%CI 0.080-0.591, P=0.003), higher hsCRP (OR=1.276, 95%CI 1.066-1.528, P=0.008), and higher 4 h D/Pcr (OR=1.395, 95%CI 1.014-1.919, P=0.041) were independent risk factors for patients with hypomagnesemia. Kaplan-Meier survival curve analysis showed the cumulative survival rate of patients in low-magnesium group was significantly lower than that of control group (Log-rank χ2=5.388, P=0.020). Fine-Gray model analysis showed the cumulative CVD survival rate of low-magnesium group was significantly lower than that of control group (Gray=6.915, P=0.009). Multivariate-corrected Cox regression model and competitive risk model analysis showed that higher serum magnesium level was a protective factor for all-cause mortality and CVD mortality when serum magnesium was used as a continuous variable (HR=0.137, 95%CI 0.020-0.946, P=0.044; SHR=0.037, 95%CI 0.002-0.636, P=0.023, respectively). Hypomagnesemia was an independent risk factor for all-cause mortality and CVD mortality when serum magnesium was used as categorical variable (HR=1.864, 95%CI 1.044-3.328, P=0.035; SHR=2.117, 95%CI 1.147-3.679, P=0.029, respectively). Conclusions Hypomagnesemia is susceptible to peritoneal dialysis patients with hypoalbuminemia, hypophosphatemia, higher hsCRP and higher peritoneal transport characteristics. Hypomagnesemia is an independent risk factor for CVD mortality and all-cause mortality in peritoneal dialysis patients.     

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.     

Clinical features and treatment outcomes of early-onset peritoneal dialysis-associated peritonitis: a multi-center retrospective study

Objective To explore the clinical characteristics and treatment outcomes of early-onset peritoneal dialysis-associated peritonitis (EOP). Methods Clinical data of patients with peritoneal dialysis-associated peritonitis (PDAP) from 2013 to 2018 in four tertiary hospitals of Jilin province were collected retrospectively. According to whether the dialysis time of the first PDAP was ≤12 months or not, the subjects were divided into EOP group (≤12 months) and late-onset PDAP (LOP) group (＞12 months) , and clinical data, pathogenic bacteria, treatment outcomes of PDAP and prognosis of two groups were compared. Results A total of 575 patients were included, including 314 patients in the EOP group, with age of (56.53±15.57) years and 152 females (48.4%), and 261 patients in the LOP group, with age of (56.61±14.42) years old and 144 females (55.2%). Compared with LOP group, the proportion of pathogenic bacteria culture-negative in EOP group was higher and the proportion of streptococcal infection was lower (both P＜0.05). The initial treatment efficiency and cure rate of EOP group were higher than that of LOP group, while the extubation rate was lower than that of LOP group (all P＜0.05). Multivariate logistic analysis indicated that the cure rate of EOP was 79% higher than that of LOP (OR=1.79, 95%CI 1.13-2.82, P=0.012), and the extubation rate of EOP was 68% lower than that of LOP (OR=0.32, 95%CI 0.15-0.66, P=0.002). Kaplan-Meier survival curve showed that the cumulative rates of multiple PDAP, technical failure, all-cause death, and composite end points (technical failure or all-cause death) in EOP group were higher than those in LOP group (P≤0.001). After correcting for confounding factors by multivariate Cox proportional hazard regression, the risk of multiple PDAP, technical failure, all-cause death, and composite endpoint (technical failure or all-cause death) in EOP group was 2.02 times (HR=2.02, 95%CI 1.26-3.24, P=0.004), 2.53 times (HR=2.53, 95%CI 1.58-4.05, P＜0.001), 2.66 times (HR=2.66, 95%CI 1.70-4.16, P＜0.001) and 2.48 times (HR=2.48, 95%CI 1.78-3.43, P＜0.001) of LOP group respectively. Conclusion The treatment outcome of the first PDAP of EOP patients is good, but the long-term prognosis is poor.     

Effects of timing of dialysis initiation on the prognosis of peritoneal dialysis patients: a retrospective cohort study

Objective To analyze the effects of dialysis therapy initiation on the prognosis of peritoneal dialysis (PD) patients. Methods PD patients who were newly catheterization and long-term followed-up in Peking University Shenzhen Hospital from January 1, 2012 to March 25, 2019 were retrospectively analyzed. According to the estimate glomerular filtration rate (eGFR) at the time of patients catheterization, the patients were divided into early-dialysis group [eGFR＞5.5 ml?min-1?(1.73 m2)-1] and late-dialysis group [eGFR≤5.5 ml?min-1?(1.73 m2)-1]. The endpoint events were transferred to other renal replacement therapy (such as hemodialysis, kidney transplantation) or death. Kaplan-Meier method was used to draw survival curve, and log-rank test was used to compare the difference of survival rate between the two groups. Cox proportional hazard model was used to analyze the influencing factors of all-cause death and technical death in PD patients. Results A total of 342 PD patients were enrolled in this study, and there were 165 cases and 177 cases in the early-dialysis and the late-dialysis group respectively. Compared with the early-dialysis group, the proportion of patients with diabetes and men, and the level of hemoglobin, serum calcium and CO2 binding capacity in the late-dialysis group were lower, while the incidence of hypertension, serum phosphorus, blood uric acid and blood urea nitrogen level were higher in the late-dialysis group (all P＜0.05). The median follow-up time was 33(16, 57) months. Kaplan-Meier survival analysis showed that the cumulative survival rate of late-dialysis group was significantly higher than that of early-dialysis group (Log-rank χ2=12.004, P＜0.001). After adjusting for gender, age of catheterization, body mass index (BMI), diabetes mellitus and hypertension, the risk ratio of all-cause death in the early-dialysis group was 1.950 times higher than that in the late-dialysis group (HR=1.950, 95%CI 1.019-3.730, P=0.044). Subgroup analysis showed that the timing of dialysis and the risk of end-point events were not affected by BMI, diabetes stratification and other factors (interactive P＞0.05), but there was interaction between dialysis time and catheter age (interactive P＜0.05). According to the age of catheterization, the risk of all-cause death were higher in the early dialysis group at a young age (≤48 years old) (HR=21.287, 95%CI 2.609-173.665, P=0.004). Conclusions The mortality rate of PD patients is higher in early-dialysis group, which is independent of gender, age, BMI, diabetes and hypertension. The difference is more distinct in low age group.     

Sclerosing encapsulating peritonitis in a child secondary to peritoneal dialysis

Sclerosing encapsulating peritonitis, or “abdominal cocoon,” is a rare but serious complication of continuous ambulatory peritoneal dialysis. It is characterized by the diffuse appearance of marked sclerotic thickening of the peritoneal membrane resulting in intestinal obstruction.A 14-year-old adolescent boy with a history of end-stage renal failure on continuous ambulatory peritoneal dialysis presented with symptoms of acute intestinal obstruction. A computed tomography scan of the abdomen revealed distended small bowel loops clustered and displaced to the right upper quadrant. The overlying peritoneum was markedly thickened and calcified. Laparotomy confirmed the diagnosis of sclerosing encapsulating peritonitis and the patient was treated with excision of the fibrocollagenous membrane. Postoperatively, he had prolonged ileus requiring parenteral nutritional support and peritoneal dialysis was restarted on postoperative day 10.A high degree of cognizance is needed to facilitate diagnosis and treatment of this uncommon and potentially life-threatening condition.     

腹膜透析患者血脂联素与动脉粥样硬化性疾病的关系

目的 探讨血脂联素(ADPN)与尿毒症腹膜透析(腹透)患者炎症及动脉粥样硬化 的关系。方法 采用酶联免疫复合物法测定正常对照组与59例规律性腹透患者血清ADPN水 平,并对这些腹透患者进行为期(10．0±1．7)月的随访。分析血清ADPN水平与血脂、炎症指标、 颈动脉内膜厚度、颈动脉斑块、既往心血管病(CVD)史和心血管预后的关系。结果 与正常对照 组相比,腹透组患者的血清ADPN水平显著升高[(13．09±7．54)μg／ml比(6．65±4．33)μg／ml,P= 0．001]。腹透患者血清ADPN与年龄、体重指数(BMI)、甘油三酯、C-反应蛋白(CRP)水平呈负相 关;与高密度脂蛋白(HDL)呈正相关。血清ADPN水平在有颈动脉斑块及动脉粥样硬化性心血 管疾病病史的腹透患者中较低。在随访期内有CVD事件发生组血清ADPN水平与无CVD事件 发生组相比显著降低。结论 血清ADPN水平与脂代谢异常、炎症和动脉粥样硬化性疾病有关, 血清ADPN较高的患者发生CVD事件的危险性较低。在腹透患者中,ADPN可能具有心血管的 保护作用。     

Value of albumin dialysis therapy in severe liver insufficiency

A blood purification system, molecular adsorbents re-circulating system (MARS), is based on the removal of both protein-bound and water-soluble substances and toxins in the liver. We treated a total of 88 patients within 2 years. Of these patients, 45 had acute liver failure (ALF), 31 had acute decompensation of chronic liver disease, eight had graft failure and four had miscellaneous conditions. Of the patients with ALF, 80% survived; in 23 patients their own liver recovered and 13 patients underwent successful transplantation. Only 23% of patients with acute-on-chronic liver failure survived. Most of them were not considered for transplantation due to their having liver failure from alcoholism and from not abstaining from drinking. MARS is a promising therapy for ALF, allowing the patients own liver to recover or allowing enough time to find a liver graft. Best results were achieved in patients who had been intoxicated with a lethal dose of toxin. On the other hand, we did not observe much benefit in patients with severe acute-on-chronic liver failure (AcoChr) who did not undergo liver transplantation.     

Prevalence of co-morbidity in different European RRT populations and its effect on access to renal transplantation.

BACKGROUND: This study compared the prevalence of co-morbidity in patients starting renal replacement therapy (RRT) between European countries and further examined how co-morbidity affects access to transplantation. METHODS: In this ERA-EDTA registry special study, 17907 patients from Austria, Catalonia (Spain), Lombardy (Italy), Norway, and the UK (England/Wales) were included (1994-2001). Co-morbidity was recorded at the start of RRT. RESULTS: The prevalence of co-morbidity was: diabetes mellitus (DM) (primary renal disease and co-morbidity) 28%, ischaemic heart disease (IHD) 23%, peripheral vascular disease (PVD) 24%, cerebrovascular disease (CVD) 14% and malignancy 11%. With exception of malignancy, the prevalence of co-morbidity was highest in Austria, but differences were small among other countries. With exception of DM, males suffered more often from co-morbidity than females. In general, the percentage of haemodialysis was higher in patients with co-morbidity, but treatment modality differed substantially between countries. Using a Cox regression with adjustment for demographics, country, year of start and other co-morbidities, the presence of each of the co-morbid conditions made it less likely [RR; 95%CI] to receive a transplant within 4 years: DM [0.79; 0.70-0.88], IHD [0.59; 0.50-0.70], PVD [0.57; 0.49-0.67], CVD [0.49; 0.39-0.61], and malignancy [0.32; 0.24-0.42]. The age, gender and year of start adjusted relative risk [95%CI] to receive a renal transplant within 4 years ranged from 0.23 [0.19-0.27] for Lombardy (Italy) to 3.86 [3.36-4.45] for Norway (Austria = reference). These international differences existed for patients with and without co-morbidity. CONCLUSIONS: The prevalence of co-morbidity was highest in Austria but differences were small among other countries. The access to a renal graft was most affected by the presence of malignancy and least affected by the presence of DM. International differences in access to transplantation were only partly due to co-morbid variability.     

Left ventricular systolic and diastolic function and carotid intima-media thickness in pediatric dialysis patients

Background  Cardiovascular complications are common in patients with end-stage renal disease (ESRD). We aimed to investigate left ventricular (LV) function and carotid intima-media thickness (cIMT) in children and adolescents with ESRD. Methods  This study included 38 ESRD patients (15 hemodialysis and 23 peritoneal dialysis) and 17 age- and sex-matched healthy subjects. Results  The ESRD patients had significantly lower mean mitral E/A ratio, and higher left ventricular mass index (LVMI) and cIMT than the control group. Compared with PD patients, HD patients had worse LV diastolic function. In stepwise linear regression analysis, LVMI (P = 0.043) and hemoglobin (P = 0.015) turned out to be independent variables for predicting diastolic dysfunction (reduced E/A ratio), and the only significant predictor of cIMT was indexed diastolic blood pressure (DBP) (P = 0.035). Conclusion  Cardiovascular structure and function abnormalities are also common in pediatric dialysis patients, as in adults. Furthermore our data indicated that hemodialysis was disadvantageous for preserving LV diastolic function as compared with peritoneal dialysis.     

Abdominal wall recurrence of Hilar bile duct cancer 12 years after a curative resection: Report of a case

A 74-year-old woman was diagnosed with hilar bile duct cancer, and underwent a curative resection of the bile duct and the left and caudate lobes of the liver in 1995. Ten years later (April 2005), she noted a small mass in the abdominal wall. The mass slowly enlarged to reach 4 cm in diameter by January 2007. With a diagnosis of a possible recurrence of bile duct cancer, a laparotomy was thus performed. The abdominal wall tumor was buried in the rectus abdominis muscle and was tightly attached to the ileum. The lesion was resected en bloc with the associated rectus muscle and ileocecal region. A histopathological examination of the resected specimen revealed tubular adenocarcinoma that closely resembled the original primary bile duct cancer. In addition, the immunohistochemical staining pattern of the abdominal tumor was identical to that of the original bile duct cancer. This indicated that the abdominal tumor represented a local recurrence (probably due to peritoneal implantation) at 12 years after the resection of the hilar bile duct cancer. This case emphasizes that long-time surveillance is required for patients with bile duct cancer, even if they have survived without recurrence for more than 5 years after a curative resection.