Volume expansion and sodium balance in peritoneal dialysis patients. Part II: Newer insights in management.

As noted in part I of this article, emerging evidence indicates that overt and (more commonly) subclinical volume expansion is frequent in patients on peritoneal dialysis (PD). That expansion in turn leads to hypertension. With loss of residual renal function, the hypertension becomes difficult to control even with increasing doses and varieties of antihypertensive drugs.

Volume expansion and sodium balance in peritoneal dialysis patients. Part I: Recent concepts in pathogenesis.

Cardiovascular disease is a leading cause of death in patients with end-stage renal disease. Uncontrolled hypertension and volume expansion contribute to alternations in left ventricular geometry and are independent predictors of poor survival in dialysis patients. Excessive salt intake is a major handicap with loss of residual renal function.

Structural changes in silicon rubber peritoneal dialysis catheters in patients using mupirocin at the exit site.

Structural damage to polyurethane PD (peritoneal dialysis) catheters in patients using mupirocin ointment is widely appreciated, but damage to silicon rubber PD catheters is less well described. Ten catheters (6.6%) out of 152 were found to have structural alterations such as opacification, ballooning, thinning, and rupture.

The implications of the ADEMEX study for the peritoneal dialysis prescription: the role of small solute clearance versus salt and water removal.

Purpose Of Review: This review examines the results of the ADEMEX (Adequacy of Peritoneal Dialysis in Mexico) study in the context of other recent advances in peritoneal dialysis, and assesses the implication of this new knowledge for the optimal peritoneal dialysis prescription.

Recent Findings: The prospective randomized controlled ADEMEX study demonstrated no survival advantage of an increased dose of peritoneal small molecule clearance delivered by chronic ambulatory peritoneal dialysis. Coincident with this finding, there has been increasing awareness that many peritoneal dialysis patients are volume expanded, and that there are adverse cardiovascular consequences to this chronic overhydration.

Chiropody may prevent amputations in diabetic patients on peritoneal dialysis.

Background: A multidisciplinary approach has been shown to be of benefit in the prevention of lower limb ulceration and amputation in patients with diabetes, but there is less information on the role of such an approach in patients receiving dialysis treatment.

Objective: The purpose of the present study was to determine whether the institution of a chiropody program would result in fewer amputations in diabetic patients on peritoneal dialysis (PD).

Design: Retrospective chart review.

Peritoneal dialysis in the nursing home.

Background: During the past few decades, the demographics of end stage renal disease have been changed significantly with the emerging predominance of elderly patients. Elderly dialysis patients are usually more dependent and may need long-term placement in a long-term care facility. Failure to meet the needs of these patients may have a significant impact on the peritoneal dialysis program.

Longterm followup of childhood lupus nephritis.

Objective: To determine the longterm outcome in children with onset of lupus nephritis before 18 years of age.

Methods: Sixty-seven patients with onset of lupus nephritis prior to age 18 were identified. The mean followup time was 11 years (range 5-19).

Predictors of outcome following bacterial peritonitis in peritoneal dialysis.

Objective: No studies have been done to examine factors that predict the outcome of bacterial peritonitis during peritoneal dialysis (PD), beyond the contribution of the organism causing the peritonitis, concurrent exit-site or tunnel infection, and abdominal catastrophes.

Design: In this study we examined several clinical and laboratory parameters that might predict the outcome of an episode of bacterial peritonitis. Between March 1995 and July 2000, we identified 399 episodes of bacterial peritonitis in 191 patients on dialysis.

Hypotension in patients on chronic peritoneal dialysis: etiology, management, and outcome.

We retrospectively evaluated the phenomenon of arterial hypotension in peritoneal dialysis (PD) in a large cohort of 633 PD patients from two centers (Toronto Western Hospital, Toronto, Canada, and Division of Nephrology, Democritus University of Thrace, Greece), thus extending our previously reported experience for an additional 6 years (1995-2000). Together, the units had 81 hypotensive patients (12.8%), whose mean age was 63.

What's new in peritoneal dialysis: biocompatibility and continuous flow peritoneal dialysis.

Purpose Of Review: This review examines recent developments in the understanding of the effect of conventional, bioincompatible peritoneal dialysis fluids on structural and functional changes in the peritoneal membrane. Emphasis is placed on the clinically relevant outcome of failure of long-term peritoneal dialysis. Therapeutic strategies to prevent technique failure, including the use of new peritoneal dialysis fluids and continuous flow peritoneal dialysis, are explored.

Continued transplant immunosuppression may prolong survival after return to peritoneal dialysis: results of a decision analysis.

Background: Patient survival is prolonged in those with residual renal function. The risks of opportunistic infection and malignancy militate against a widespread policy of maintaining immunosuppression in those returning to peritoneal dialysis after a failed allograft. We set out to test the hypothesis that patients returning to peritoneal dialysis after a failed transplant benefit from continued immunosuppression.

Normal or low initial PTH levels are not a predictor of morbidity/mortality in patients undergoing chronic peritoneal dialysis.

Objective: During the past few decades, the pattern of bone disease in uremic patients has changed significantly. There has been an increase in the number of patients with normal or low initial parathyroid hormone (PTH) levels, particularly in patients on chronic peritoneal dialysis (CPD). Previous authors have described a higher prevalence of bone pain, microfractures, and fractures, and higher mortality among these patients.

A unique renal lesion in common variable immunodeficiency.

This article reports the case of a 33-year-old woman with common variable immunodeficiency (CVI) who developed renal failure 17 years after diagnosis and initiation of treatment with monthly IVIG. A renal biopsy revealed mesangial and paramesangial immune complex deposition and interstitial granulomatous infiltration. Renal function improved with oral corticosteroids, but did not return to normal.

Emergence of mupirocin-resistant Staphylococcus aureus in chronic peritoneal dialysis patients using mupirocin prophylaxis to prevent exit-site infection.

Objective: To determine the prevalence of the carriage of Staphylococcus aureus (SA), methicillin-resistant Staphylococcus aureus (MRSA), and mupirocin-resistant Staphylococcus aureus (MuRSA) in chronic peritoneal dialysis (CPD) patients after 4 years of prophylactic mupirocin application to the exit site, in a peritoneal dialysis unit.

Methods: Three swabs were collected from the nares, axillae/groin, and exit site, respectively, from 149 patients on CPD between May and July 2001. All swabs were cultured on solid selective agar (mannitol salt agar) and in mannitol salt broth.

Long-term blood pressure control in a cohort of peritoneal dialysis patients and its association with residual renal function.

Background: Hypertension is the prime contributor for cardiovascular mortality in the dialysis population. Peritoneal dialysis (PD) has been thought to improve blood pressure (BP) control in the short term, but the long-term benefits are not conclusively proven. We aimed to evaluate the degree of BP control in PD patients in the long term and analyse the factors associated with poor control.

Late renal transplant failure: an adverse prognostic factor at initiation of peritoneal dialysis.

Background: Early renal transplant failure necessitating a return to dialysis has been shown to be a poor prognostic factor for survival. Little is known about the outcome of patients with late transplant failure returning to dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients returning to dialysis.

Chronic peritoneal dialysis in octogenarians.

Background: During the past few decades the pattern of end-stage renal failure disease has changed with increasing number of elderly patients admitted for dialysis. In spite of their increasing number, little is known about the optimal mode of therapy of the 'old old' (those >or=80 years) patients.

Methods: In this retrospective study, we analysed the results of treatment of 31 non-institutionalized 'old old' patients at Toronto Western Hospital (17) and Scarborough General Hospital (14) and seven institutionalized patients in chronic care, Riverdale Hospital.

Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study.

Studies of the adequacy of peritoneal dialysis and recommendations have assumed that renal and peritoneal clearances are comparable and therefore additive. The CANUSA data were reanalyzed in an effort to address this assumption. Among the 680 patients in the original CANUSA study, 601 had all of the variables of interest for this report.

Increased mortality of elderly female peritoneal dialysis patients with diabetes--a descriptive analysis.

Three recent studies using registry data from the United States, in comparing the mortality risks between peritoneal dialysis (PD) and hemodialysis (HD), have consistently found that elderly diabetic women on PD have a higher mortality risk as compared with their counterparts on HD. Though the cause for this observation is not clear, the phenomenon may be unique to the United States. Alternatively, a selection bias impossible to decipher may be at work in these studies, as none of them have data on comorbidity, nutrition, or adequacy of dialysis.