Influence of peritoneal residual volume on the results of the peritoneal equilibration test. Prospective study.

BACKGROUND: Categorization of the capacity of ultrafiltration during a peritoneal equilibration test (PET) is a usual step during the monitoring of peritoneal transport characteristics of Peritoneal Dialysis (PD) patients. Quantifying the peritoneal residual volume (Vr) after the dwell preceding the PET (Vrpre) and at the end of the test (Vrpost) could help to improve the accuracy of the estimation of this variable. METHOD: Following a prospective design, we calculated Vrpre and Vrpost in 116 patients, incident or prevalent on DP, who underwent one or two (n = 27) PET with 3,86/4,25% glucose-based PD solutions and complete drainage at 60 min. We evaluated the consistency of Vr by comparing Vrpre and Vrpost, as also these two parameters in repeated tests. We scrutinized potential associations between demographic and clinical factors, on one side, and the amount of Vr on the other, as also the impact of correcting ultrafiltration during PET for Vr on the categorization of the capacity of ultrafiltration. RESULTS: As a mean, Vrpost was larger than Vrpre. Consequently, correction of ultrafiltration for Vr resulted in significantly higher values than those obtained according to the standard procedure (494 vs. 449 mL, p < 0,0005). We disclosed marked inconsistencies for different estimations of Vr in the same patients (Vrpre vs Vrpost and repeated PET studies). Moreover, no demographic or clinical variable was able to predict the amount of Vr. We observed a significant deviation (>200 mL) between both methods of estimation of the capacity of utrafiltration in only 12,9% of the patients. However, 21,1% of the patients categorized as cases of ultrafiltration failure according to the standard procedure did not maintain this condition after correction for Vr. CONCLUSIONS: Correction for Vr of the capacity of ultrafiltration during a PET carries, as a mean, a minor impact on the categorization of this parameter. However, the results of the test can be significantly affected in 12,9% of the cases. We have been unable to detect demographic or clinical predictors of Vr, which suggests a random component for the mechanics of single peritoneal exchanges. We suggest that Vr should be estimated at the time of categorizing the capacity of ultrafiltration, whenever inconsistencies during serial PET studies are detected.

How a Bottom-Up Multi-Stakeholder Initiative Helped Transform the Renal Replacement Therapy Landscape in Spain.

Healthcare reforms aim to change certain parts of the health system to improve quality of care, access, or financial sustainability. Traditionally, healthcare reform is understood as an action undertaken by a government at a national or local level. However, bottom-up changes can also lead to improvements in the health system. This paper describes the efforts of a coordinated multi-stakeholder advocacy group in Spain to promote a more cost-effective and patient-centred treatment for people receiving renal replacement therapy and assesses the outcomes of their advocacy for health system financing and patient satisfaction. It concludes that bottom-up initiatives do indeed have the power to change health policy and that policy makers should pay attention to their arguments.

Analysis of Ultrafiltration Failure Diagnosed at the Initiation of Peritoneal Dialysis with the Help of Peritoneal Equilibration Tests with Complete Drainage at Sixty Minutes. A Longitudinal Study.

UNLABELLED: ♦ BACKGROUND: Ultrafiltration failure (UFF) diagnosed at the initiation of peritoneal dialysis (PD) has been insufficiently characterized. In particular, few longitudinal studies have analyzed the time course of water transport in patients with this complication. ♦ OBJECTIVE: To investigate the time course of peritoneal water transport during the first year on PD in patients presenting UFF since the initiation of this therapy (study group). ♦ METHOD: Prospective, observational, single-center design. We analyzed, at baseline and after 1 year of follow-up, peritoneal water transport in 19 patients incident on PD with UFF. We used incident patients without UFF as a control group. Water transport was characterized with the help of 3.86/4.25% dextrose-based peritoneal equilibration tests (PETs) with complete drainage at 60 minutes. ♦ RESULTS: The study group revealed a disorder of water transport affecting both small-pore ultrafiltration (SPUF) (p = 0.054 vs incident without UFF) and free water transport (FWT) (p = 0.001). After 1 year of follow-up, FWT displayed a general increasing trend in the study group (mean variation 48.9 mL, 95% confidence interval [CI] 15.5, 82.2, p = 0.012), while the behavior of SPUF was less predictable (-4.8 mL, 95% CI -61.4, 71.1, p = 0.85). These changes were not observed in incident patients without UFF. Neither initial clinical characteristics, baseline PET-derived parameters, or suffering peritoneal infections during the first year predicted the time course of the capacity of UF in the study group. Recovery from incident UFF was apparently linked to improvement of SPUF. ♦ CONCLUSIONS: Patients with UFF at the start of PD suffer a disorder of peritoneal water transport affecting both FWT and SPUF. Free water transport increases systematically in these patients after 1 year of follow-up. The evolution of SPUF is less predictable, and improvement of this parameter marks reversibility of this complication.

Effectiveness of treatment with oral paricalcitol in patients on peritoneal dialysis: a Spanish multicenter study.

AIMS: Recently, oral form of paricalcitol has allowed extension of treatment to ambulatory patients on peritoneal dialysis but few data have been published about the benefits of paricalcitol in this subgroup. A multicenter, retrospective study was carried out to increase current knowledge on the effectiveness and safety of paricalcitol in 162 peritoneal dialyzed patients with secondary hyperparathyroidism. METHODS: Case histories of patients treated with paricalcitol for at least 6 months were reviewed to extract data on 12 biochemical parameters related to bone disease and health status. Changes in these parameters were described. Doses of paricalcitol and other concomitant treatments were evaluated at least every 3 months. RESULTS: 99 men (61.1%) and 63 women (38.9%) with an average age of 62.07 years were included. PTH levels showed an acute decrease in the three first months (35.88%) and a global decrease at month 6 of 42.39%. A slight increase in calcium was observed (p < 0.001) but it remained between normal range values. Only 5 patients presented serum calcium over 10.2 in two consecutive measurements. No changes were found in phosphorus, calcium-phosphorus product, hemoglobin, alkaline phosphatase, GGT, albumin, PCR inflammatory markers, pH and bicarbonate. The decrease in proteinuria levels was nearly statistically significant (p = 0.061). Only 6 patients (0.36%) abandoned the treatment. CONCLUSIONS: Paricalcitol therapy was well tolerated with a high effectiveness in patients on peritoneal dialysis. A slight increase in serum calcium levels was observed, although within normal ranges. No changes in other biochemical parameters related to bone disease could be associated to paricalcitol with data compiled in our study. Paricalcitol seems to have a protective effect on proteinuria levels.

Effect of self-administered intraperitoneal bemiparin on peritoneal transport and ultrafiltration capacity in peritoneal dialysis patients with membrane dysfunction. A randomized, multi-centre open clinical trial.

BACKGROUND: Progressive peritoneal membrane injury and dysfunction are feared repercussions of peritoneal dialysis (PD), and may compromise the long-term feasibility of this therapy. Different strategies have been attempted to prevent or reverse this complication with limited success. METHODS: We performed a randomized, open multi-centre trial, aimed at scrutinizing the efficacy of self-administered intraperitoneal (i.p.) bemiparin (BM) to modulate peritoneal membrane dysfunction. The main outcome variables were peritoneal creatinine transport and the ultrafiltration (UF) capacity, estimated during consecutive peritoneal equilibration tests. The trial included a control group who did not undergo intervention. The treatment phase lasted 16 weeks with a post-study follow-up of 8 weeks. RESULTS: Intraperitoneal BM did not significantly improve creatinine transport or the UF capacity, when the whole group was considered. However, we observed a time-limited improvement in the UF capacity for the subgroup of patients with overt UF failure, which was not observed in the control group. Intraperitoneal injection of BM did not carry an increased risk of peritoneal infection or major haemorrhagic complications. CONCLUSIONS: Our data do not support the systematic use of BM for management of peritoneal membrane dysfunction in PD patients. Further studies on the usefulness of this approach in patients with overt UF failure are warranted. Intraperitoneal administration of BM is safe in PD patients, provided regulated procedures are respected.

Categorization of sodium sieving by 2.27% and 3.86% peritoneal equilibration tests--a comparative analysis in the clinical setting.

BACKGROUND: Analysis of the dialysate sodium concentration during a peritoneal equilibration test (PET) provides information on the rates of water and solute transport through different membrane pathways. A hypertonic (3.86%) glucose-based dialysate may enhance the accuracy of analysis. There are still gaps in our knowledge regarding this question, in the clinical setting. Objective. The aim of this study was to compare the categorization of the sodium sieving effect in peritoneal dialysis (PD) patients by 2.27% and 3.86% PETs, and to disclose clinical correlates of this phenomenon. Method. Ninety PD patients underwent prospectively 2.27% and 3.86% modified (dialysate samples at 0, 60, 90, 120 and 240 min) PETs, in a random order. We searched for differences in the time profiles of sodium sieving and its categorization. We correlated sodium sieving with ultrafiltration (UF) and solute transport capacity, as also with selected clinical and demographic variables, using a multivariate approach. RESULTS: The maximum dip in the dialysate sodium concentration (11.1 mM/L, 3.86% versus 7.1 mM/L, 2.27%, P < 0.001) was most common after 90 min in the 3.86% PET, with the 2.27% test somewhere between 60 and 90 min. Low sodium sieving (defined by a dip <5 mM/L at 60 min) was observed in 8.9% of the patients in the 3.86% test. The same limit categorized 34.4% of the patients as low sieving in the 2.27% test (100.0% sensitivity and 72.0% specificity, using 3.86% as a reference). UF and D/P(240 min) creatinine were independent predictors of the sodium sieving effect in both tests. Moreover, multivariate analysis disclosed a consistent inverse correlation between GFR and sodium sieving in both the 2.27% (B = -0.23, 95% CI -0.40, -0.07, P = 0.006) and 3.86% PET (B = -0.46, 95% CI -0.65, -0.26, P < 0.0005). CONCLUSIONS: The standard 2.27% PET permits some categorization of sodium sieving in PD patients. However, the information provided by this test lacks the discriminatory capacity of the 3.86% PET, which should be considered the one for reference for this purpose. GFR keeps a consistent inverse correlation with the intensity of sodium sieving in both the 2.27% and 3.86% PET.

Treatment of peritoneal dialysis-related peritonitis with ciprofloxacin monotherapy: clinical outcomes and bacterial susceptibility over two decades.

BACKGROUND: There is controversy about the preferred initial antibiotic therapy for peritoneal dialysis (PD)-related peritonitis. Quinolones have been used extensively in this setting, yet their long-term effectiveness is unknown. AIM: To analyze the results of a protocol of treatment of PD-related peritonitis with ciprofloxacin, maintained over two decades. METHOD: We analyzed the clinical outcome of 682 episodes of bacterial peritonitis treated with intraperitoneal ciprofloxacin monotherapy, and the time course of bacterial susceptibility to this antimicrobial, in a historical cohort of 641 PD patients (1988-2007). Main outcome variables included changes to initial therapy and rates of hospital admission, catheter removal, relapse, reinfection, PD dropout, and mortality. For comparisons we divided the study period into phases A (1988-1994), B (1995-2000), and C (2001-2007). RESULTS: The incidence of Staphylococcus aureus peritonitis decreased, while the incidences of polymicrobial and negative-culture peritonitis increased after phase A. In vitro susceptibility to ciprofloxacin decreased significantly only among coagulase-negative staphylococci (87.0% susceptible strains in phase A vs 70.0% in B and 70.1% in C, p = 0.006). Overall success rates (catheter not removed and ongoing PD after the episode) remained stable, at over 85%. However, the proportion of patients treated solely with ciprofloxacin declined from 75.7% (A) to 47.3% (B) to 32.4% (C) (p < 0.0005) and admission rates increased from 12.7% to 16.8% to 24.9% respectively (p = 0.001). These changes affected all the etiologic groups except culture-negative peritonitis. In vitro resistance to ciprofloxacin was a marker of multiresistance and correlated strongly with clinical outcome of peritonitis. Among isolates susceptible to ciprofloxacin, changing initial therapy for any reason also predicted a poor outcome. CONCLUSIONS: Following satisfactory early results, the effectiveness of ciprofloxacin as monotherapy for PD-related peritonitis has declined markedly in the long term. This decline cannot be explained solely by a decrease of in vitro susceptibility to this antimicrobial, which was significant only among coagulase-negative staphylococci. Resistance to ciprofloxacin is a strong marker of in vitro multiresistance and poor clinical outcome of peritonitis.

Serum levels of anti-alphaGalactosyl antibodies predict survival and peritoneal dialysis-related enteric peritonitis rates in patients undergoing renal replacement therapy.

BACKGROUND: Anti-Galalpha1-3Gal antibodies (anti-alphaGal) represent a significant fraction of natural antibodies and were implicated in several disease states, yet their origin and physiological significance remain largely undisclosed. METHODS: Under a prospective observational design, we estimated anti-alphaGal immunoglobulin G (IgG)/IgM and antipig hemolytic antibody (APA) levels in 133 patients starting dialysis therapy and again after a 1-year follow-up. We used baseline data to show correlations with demographic, nutritional, inflammatory, and anemia markers and analyzed their correlation with outcomes by using univariate and multivariate strategies of survival analysis. RESULTS: Serum anti-alphaGal and APA levels showed wide baseline variability, but remained relatively stable in time. Both were measurable in dialysate of peritoneal dialysis (PD) patients, showing close correlation to serum levels. We observed no association between levels of anti-alphaGal/APA and nutritional markers, but showed direct correlations of anti-alphaGal IgM (P = 0.005) and APA levels (P = 0.001) with tumor necrosis factor alpha (TNF-alpha) levels. High APA levels also were associated with severe anemia (P = 0.006). High baseline anti-alphaGal IgM (P = 0.03) and APA levels (P = 0.045) predicted later risk for enteric peritonitis in PD patients. Finally, univariate and multivariate analyses showed a consistent association between high baseline anti-alphaGal IgM (P = 0.014) and APA (P = 0.021) levels and global risk for mortality during follow-up. CONCLUSION: Anti-alphaGal IgM and APA levels at the start of dialysis therapy are significant predictors of later risk for mortality and, in PD patients, enteric peritonitis. Both correlate directly with TNF-alpha levels and, in the case of APA, severity of anemia in these patients.

Incidence and significance of peritoneal eosinophilia during peritoneal dialysis-related peritonitis.

OBJECTIVE: To determine the incidence and significance of peritoneal eosinophilia (PEo) during peritoneal dialysis (PD)-related peritonitis. DESIGN: Retrospective observational study. SETTING: Tertiary-care public hospital. PATIENTS AND METHOD: We performed a cytological study of dialysate at the start of 465 cases of peritonitis diagnosed between January 1987 and May 2002. Cases associated with PEo (> 10% eosinophils) were classified according to their infectious or seemingly noninfectious origin. We compared the two groups, trying to disclose differentiating patterns of presentation. RESULTS: We found PEo in 42 cases. Infectious peritonitis was the final diagnosis in 22 of the 42 cases; a diagnosis of idiopathic eosinophilic peritonitis was finally established in 20 cases. The etiologic spectrum of infectious peritonitis with PEo did not differ markedly from the global spectrum of peritonitis in our unit. Infectious peritonitis with PEo tended to appear later in the course of PD therapy, presented with more severe clinical symptoms, displayed higher total peritoneal leukocyte and neutrophil counts, and showed lower degrees of PEo than idiopathic eosinophilic peritonitis, but overlap between the groups was significant. CONCLUSIONS: Peritoneal eosinophilia is infrequent but not rare during infectious PD-related peritonitis. Our findings agree with established concepts on idiopathic eosinophilic peritonitis, but overlap in presentation with infectious eosinophilic peritonitis is significant, which should be taken into consideration at the time of planning therapy for this condition.

Sodium removal in patients undergoing CAPD and automated peritoneal dialysis.

OBJECTIVES: To compare sodium removal in continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) patients, and to identify the main factors that modify Na removal in clinical practice in these patients. DESIGN: Study in three steps. Cross-sectional observational (Study A), and longitudinal interventional (Studies B and C). PATIENTS AND METHODS: First (Study A) we carried out a cross-sectional survey of Na removal in 63 patients on CAPD and 78 patients on APD. Second (Study B), we studied Na removal in 32 patients before and after changing from CAPD to APD therapy. Finally (Study C), we analyzed the impact on Na removal of introducing icodextrin for the long dwell in 16 patients undergoing CAPD or APD. RESULTS: In Study A, total Na removal averaged 210 mmol/day for CAPD patients and 91 mmol/day for APD patients (p < 0.001); Na removal was < 100 mmol/day in 7.1% of CAPD patients and 56.4% of APD patients. Multivariate analysis identified ultrafiltration [B = 125 mmol/day, 95% confidence interval (CI) 110,140], CAPD therapy (B = 60 mmol/day, 95%CI 37, 83), and residual diuresis (B = 51 mmol/L, 95%CI 34, 69) as independent predictors of Na removal (adjusted r2 = 0.76). For APD patients, longer nocturnal dwell times and performing a supplementary diurnal exchange were also independently associated with higher Na removal rates. In Study B, Na removal decreased from 192 to 92 mmol/day (median) after the change to APD (p = 0.02). In Study C, peritoneal Na removal increased from 98 to 148 mmol/day (median) (p = 0.04) after introducing icodextrin. CONCLUSIONS: Standard APD schedules are frequently associated with poor Na removal rates. For any degree of ultrafiltration, Na removal is better in CAPD than in APD. Icodextrin, supplementary diurnal exchanges, and longer nocturnal dwell times improve Na removal in APD. Sodium removal can be estimated from ultrafiltration in patients on CAPD, but must be specifically monitored in patients on APD.