Peritoneal Dialysis International: Journal of the International Society for Peritoneal Dialysis

Peritoneal dialysis (PD) is developing rapidly in China, but because there are not enough well-trained PD doctors and nurses in more rural areas, this expansion is occurring mainly in larger cities. To address this imbalance, our center established a PD satellite center program across Guangdong Province, with the aim of extending the use and improving the quality of PD.

Sun Yat-sen University PD center is responsible for running the satellite program. The PD satellite centers are selected using specific criteria. The full-time PD physicians and nurses in the satellite centers accept a unified training program and treatment practices, and their clinical outcomes are carefully followed by our center.

The program began in January 2008, and there are now 12 PD centers from which 26 doctors and 32 nurses received PD training. Several hundred patients are now receiving PD through this program. The total number of PD patients treated by our center and the satellites increased to 1860 from 1010. The number treated in the satellite units increased to 1165 from 601. The annual dropout rate fell to 17.6% from 28.2%, and the average peritonitis incidence fell from 1 episode in 39.4 patient–months to 1 episode in 46.2 patient–months. The 1-year patient and technique survival rates increased to 84.2% from 82.0% and to 93% from 88.7% respectively.

Our PD satellite center program is a good model for increasing the use and improving the quality of PD in rural areas. We plan to expand this program to other parts of southern China.

Despite a lack of strong evidence, automated peritoneal dialysis (APD) is often prescribed on account of an expected better quality of life (QoL) than that expected with continuous ambulatory peritoneal dialysis (CAPD). Our aim was to analyze differences in QoL in patients starting dialysis on APD or on CAPD with a follow-up of 3 years.

Adult patients in the prospective NECOSAD cohort who started dialysis on APD or CAPD were included 3 months after the start of dialysis. The Medical Outcomes Survey Short Form 36 [SF-36 (Medical Outcomes Trust and QualityMetric, Lincoln, RI, USA)] and Kidney Disease and Quality of Life Short Form [KDQOL-SF (KDQOL Working Group, Santa Monica, CA, USA)] questionnaires were used to measure QoL. Differences in QoL over time were calculated using linear mixed models. Patients were followed until transplantation, death, or a first switch to any other dialysis modality.

The clinical and social characteristics of the 64 APD and 486 CAPD patients were slightly different at baseline. In the crude analysis, the pattern of the mental summary score differed between the modalities (p = 0.03, adjusted p = 0.06), because of a different pattern for role function emotional (p = 0.03, adjusted p = 0.05). The pattern of the physical summary score was not different between the groups. Scores on dialysis staff encouragement had a different pattern over time (p = 0.01), because of an in-equality in scores 3 months after the start of dialysis, which disappeared after 18 months on dialysis. Over time, patients on APD scored higher on sexual function. After adjustment for age, sex, glomerular filtration rate, comorbidity, and primary kidney disease, that difference disappeared. This study showed no major differences in QoL on the KDQOL-SF and the SF-36 between the two modalities.

To better understand the spectrum of overfill reports and their corresponding clinical severity and etiology, we conducted a review of overfill reports from the Manufacturer and User Facility Device Experience (MAUDE) database, which is within the Food and Drug Administration (FDA) Web site (www.fda.gov).

We searched the MAUDE database for events related to overfill reports between 1 January 1995 and 31 December 2008 and recorded drain volume (DV)/fill volume (FV), or DV/FV, and clinical symptoms and signs associated with the overfill report.

Among 462 MAUDE reports with a possible overfill event, 440 reports (95.2%) with a confirmed overfill event contained sufficient information to ascertain the clinical severity of the event. The number of reports with a clinical severity rating of minor, moderate, major, or death was 331, 71, 28, and 10, respectively. The median (range) DV/FV for a subgroup of 292 reports with a clinical severity rating of minor, moderate, major, or death was 1.63 (1.06 - 4.29), 1.71 (1.08 - 5.87), 2.14(1.64 - 2.61), and 2.50 (2.28 - 3.33), respectively. Insufficient drain accounted for a majority of overfill reports.

Our analysis of reports from the MAUDE database suggests an association between DV/FV and clinical severity of the reported overfill event, as well as significant patient-to-patient variability with respect to intra peritoneal volume tolerance.

Better glycemic control has been reported to slow the progression of nephropathy in predialysis diabetic patients. However, the relationship between glycemic control and residual renal function (RRF) in patients on peritoneal dialysis (PD) is uncertain.

89 incident diabetic patients on PD were recruited from 5 centers. We measured glomerular filtration rate (GFR) and hemoglobin A1c (HbA1c) within 2 months (baseline) after the start of PD and at 6 and 12 months. GFR was calculated as the average of renal creatinine and urea clearances. We analyzed whether mean HbA1c was associated with change in GFR (ΔGFR) over 1 year.

During the first year of PD, ΔGFR was -1.7 ± 3.4 mL/min/1.73 m² and was not affected by mean HbA1c. Acute hemodialysis before starting PD and mean arterial diastolic pressure were related to the decline of GFR in a multivariate analysis.

Glycemic control was not associated with change in RRF in diabetic patients during the first year after starting PD.

Volume control is critical for the success of peritoneal dialysis (PD) but dry weight in PD has been difficult to obtain. Edema free is, in general, accepted clinically as a target for volume control in PD patients. However, PD patients can be free of edema despite significant volume overload. The present study investigates the possible factors that influence the formation of pitting edema in volume-overloaded PD patients.

In this cross-sectional study, patients’ fluid status was evaluated by multifrequency bioelectrical impedance spectroscopy analysis. Values for overhydration were obtained. Patients with overhydration ≥ 2.0 kg were considered volume overloaded and were eligible for inclusion. From 1 March 2009 to 1 December 2009, a total of 96 patients on continuous ambulatory PD were included. Endothelial function was evaluated by flow-mediated dilatation (FMD). Other clinical indicators, such as blood pressure, dialysis adequacy, nutrition status, and biochemical parameters, were recorded. Patients were divided into 2 groups based on edema status: the edema group (n = 35 volume-overloaded patients with bilateral pitting edema) and the non-edema group (n = 61 volume-overloaded patients without bilateral pitting edema).

Overhydration in the edema group was significantly higher than in the non-edema group (4.28 ± 1.75 kg vs 3.12 ± 0.81 kg, p < 0.001), whereas both FMD and serum albumin in the edema group were significantly lower than in the non-edema group (6.65% ± 5.2% vs 10.3% ± 5.1%, p = 0.001; 37.6 ± 4.2 g/L vs 39.3 ± 3.5 g/L, p = 0.047, respectively). Edema status (edema = 1, non-edema = 0) was positively correlated with overhydration (r = 0.341, p < 0.001), gender (male = 1, female = 2: r = 0.184, p = 0.072), and total fluid removal (r = 0.188, p = 0.074) and negatively correlated with endothelial function, as assessed by FMD (r = -0.33, p = 0.001), and serum albumin (r = -0.18, p = 0.055). Logistic regression analysis showed that FMD [odds ratio (OR) 0.90, 95% confidence interval (CI) 0.81 - 0.99; p = 0.036], gender (male = 1, female = 2: OR 4.06, 95% CI 1.23 - 13.35; p = 0.021), overhydration (OR 3.06, 95% CI 1.53 - 6.13; p = 0.002), and serum albumin (OR 0.86, 95% CI 0.75 - 0.99; p = 0.035) were independent factors affecting the edema status of the study population.

Our study showed that endothelial function (assessed by FMD), gender, serum albumin, and over hydration are independent determinants of edema status in PD patients. This may explain why some PD patients can maintain free of edema despite significant volume overload.

There are various causes of halitosis, one of which is chronic renal failure. The objective of this study was to investigate halitosis levels in end-stage renal disease (ESRD) patients before and after peritoneal dialysis (PD) therapy.

42 subjects with ESRD were included in this study. The presence of halitosis was assessed using an organoleptic measurement and compared with blood urea nitrogen (BUN) levels and salivary flow rates. Decayed, missing, and filled teeth (DMFT) index and Community Periodontal Index (CPI) were calculated. All measurements were done before and after patients had received 3 months of PD therapy.

Mean serum BUN level was found to be lower (46.05 ± 13.30 vs 91.24 ± 31.28 mg/dL), salivary flow rate higher (0.34 ± 0.07 vs 0.26 ± 0.04 mL/minute), and halitosis level lower (2.39 ± 0.60 vs 3.90 ± 0.37) at the end of 3 months of PD therapy than at the beginning of PD therapy. There was no significant difference in CPI or DMFT index before and after PD therapy (p > 0.05). There was statistically significant positive correlation between the presence of halitosis and BUN levels (r = 0.702, p = 0.001 before PD; r = 0.45, p = 0.002 after PD) and a negative correlation between the presence of halitosis and salivary flow rates (r = -0.69, p = 0.000 before PD; r = -0.37, p = 0.01 after PD).

High BUN levels and low salivary flow rates were found to be associated with halitosis. PD may play an important role in decreasing the level of halitosis in ESRD patients.

To determine if discordance in culture results between the effluent and the tip of the peritoneal catheter had an effect on outcome in patients whose peritoneal dialysis (PD) catheter was removed mostly for nonresolving peritonitis. Reasons for and outcomes of PD catheter removal were also analyzed.

We retrospectively reviewed the charts of all PD patients with recent peritonitis for which the PD catheter was removed between 1 January 2003 and 30 April 2009. Data including basic demographics, the organism isolated from effluent and from the PD catheter, reason for catheter removal, duration of hospitalization, and development of intra-abdominal collection were extracted as well as mortality within 8 weeks post removal and return to PD after catheter removal.

Fungal peritonitis was the most common reason for PD catheter removal. 20% of the patients developed an intra-abdominal collection. Mortality related to PD catheter removal was low (3/53; 5.6%). The patients (n =53) were divided into 3 groups: group 1 (n = 20) had the same culture result of effluent and catheter tip; group 2 (n = 19) had a negative culture of the catheter tip; and group 3 (n = 14) had different organism(s) growing from effluent and catheter tip. We found no remarkable differences in duration of PD, catheter age, peritonitis rate, or mortality. Patients in group 1 had significantly more fungal peritonitis than the other 2 groups. In only 4 of the 53 patients (7.5%), the anti-infectious management was changed according to the catheter culture result.

Discordant results between catheter tip culture and effluent culture did not have a significant impact on patient outcome. Sending PD catheters for culture has limited clinical importance.

Icodextrin is widely used in peritoneal dialysis (PD); however, the safety and efficacy of icodextrin are unclear. In the present study, we performed a systematic review of randomized controlled trials (RCTs) that compared icodextrin and glucose for the once-daily long dwell in PD.

Electronic searches were performed in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to select all eligible studies. Eligible studies, as determined by consensus using predefined criteria, were reviewed, and data were extracted onto a standard form.

In the 9 RCTs that were identified, patients using icodextrin were found to have much greater net ultrafiltration (UF) and a lower incidence of negative net UF compared to patients using 1.5%, 2.5%, and 4.25% glucose solutions. Additionally, icodextrin has a markedly increased UF efficiency ratio and peritoneal clearance of creatinine and urea nitrogen, but residual renal function was not different from patients using glucose solutions for PD. No significant differences were observed between icodextrin and glucose groups with respect to risk of mortality, peritonitis, and total adverse events. Although rashes occurred significantly more often in icodextrin groups, few differences were noted between icodextrin and glucose groups when withdrawal rates secondary to adverse events were compared.

This meta-analysis suggests that icodextrin provides patients with greater fluid removal and small solute clearance and does not cause any damage to residual renal function. Icodextrin is particularly appropriate for use in patients with high peritoneal transport status.

Accumulation of advanced glycation end products (AGEs) may be involved in the pathogenesis of peritoneal membrane dysfunction. As glycoxidation may play an important role in AGE formation, peritoneal dialysis fluids with low levels of glucose degradation products (GDPs) might result in a reduction in AGE concentration in the peritoneal effluent. The aim of this study was to compare the effects of conventional glucose-containing dialysis solutions and low GDP level fluids on the concentration of the AGEs N^ε-(carboxymethyl)lysine (CML) and N^ε-(carboxyethyl)lysine (CEL) in peritoneal effluent.

Prospective randomized control study.

23 patients were treated with either conventional glucose-containing fluid (n = 11, group A) or low level GDP fluid (n = 12, group B) during a period of 12 weeks. Before and after this period, CML and CEL were measured in peritoneal effluent.

In groups A and B there were changes in CML concentrations [respectively 13.7 ± 17.0 and -16.0 ± 46.0 nmol/L (NS)] and CEL concentrations (respectively 20.3 ± 26.6 and -8.8 ± 18.9 nmol/L, p = 0.015). Residual renal function (RRF) in groups A and B was, respectively, 6.8 and 6.1 mL/min (NS). CML, but not CEL, in the peritoneal effluent was inversely related to RRF (r = -0.67, p < 0.05).

CEL, but not CML, in the peritoneal effluent appears to be influenced by the prescription of low GDP level fluid, probably due to the highly reduced concentration of methylglyoxal, which is needed for formation of CEL. CML is primarily influenced by RRF.