Regional variation in the treatment and prevention of peritoneal dialysis-related infections in the Peritoneal Dialysis Outcomes and Practice Patterns Study.

BACKGROUND: Peritoneal dialysis (PD)-related infections lead to significant morbidity. The International Society for Peritoneal Dialysis (ISPD) guidelines for the prevention and treatment of PD-related infections are based on variable evidence. We describe practice patterns across facilities participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). METHODS: PDOPPS, a prospective cohort study, enrolled nationally representative samples of PD patients in Australia/New Zealand (ANZ), Canada, Thailand, Japan, the UK and the USA. Data on PD-related infection prevention and treatment practices across facilities were obtained from a survey of medical directors'. RESULTS: A total of 170 centers, caring for >11 000 patients, were included. The proportion of facilities reporting antibiotic administration at the time of PD catheter insertion was lowest in the USA (63%) and highest in Canada and the UK (100%). Exit-site antimicrobial prophylaxis was variably used across countries, with Japan (4%) and Thailand (28%) having the lowest proportions. Exit-site mupirocin was the predominant exit-site prophylactic strategy in ANZ (56%), Canada (50%) and the UK (47%), while exit-site aminoglycosides were more common in the USA (72%). Empiric Gram-positive peritonitis treatment with vancomycin was most common in the UK (88%) and USA (83%) compared with 10-45% elsewhere. Empiric Gram-negative peritonitis treatment with aminoglycoside therapy was highest in ANZ (72%) and the UK (77%) compared with 10-45% elsewhere. CONCLUSIONS: Variation in PD-related infection prevention and treatment strategies exist across countries with limited uptake of ISPD guideline recommendations. Further work will aim to understand the impact these differences have on the wide variation in infection risk between facilities and other clinically relevant PD outcomes.

Determining Nurse Staffing for Peritoneal Dialysis Care.

There is no consensus on the ideal staffing levels for peritoneal dialysis (PD) units. The objective of this two-phase study was to evaluate nurse staffing levels in a PD unit based on activities and time spent performing them. An instrument was created based on nursing activities identified by a focus group, and the time spent performing these activities was measured over a four-month period. Forty-seven activities were identified, including care assistance activities (29), management activities (12), educational activities (5), and research activities (1). Direct patient care predominated, consuming 55.3% of overall time worked. Based on time spent per activity, we estimate that 70.2 hours of nursing care is required to care for one patient for one year.

Impact of patient training patterns on peritonitis rates in a large national cohort study.

BACKGROUND: Ideal training methods that could ensure best peritoneal dialysis (PD) outcome have not been defined in previous reports. The aim of the present study was to evaluate the impact of training characteristics on peritonitis rates in a large Brazilian cohort. METHODS: Incident patients with valid data on training recruited in the Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD II) from January 2008 to January 2011 were included. Peritonitis was diagnosed according to International Society for Peritoneal Dialysis guidelines; incidence rate of peritonitis (episodes/patient-months) and time to the first peritonitis were used as end points. RESULTS: Two thousand two hundred and forty-three adult patients were included in the analysis: 59 ± 16 years old, 51.8% female, 64.7% with ≤4 years of education. The median training time was 15 h (IQI 10-20 h). Patients were followed for a median of 11.2 months (range 3-36.5). The overall peritonitis rate was 0.29 per year at risk (1 episode/41 patient-months). The mean number of hours of training per day was 1.8 ± 2.4. Less than 1 h of training/day was associated with higher incidence rate when compared with the intervals of 1-2 h/day (P = 0.03) and >2 h/day (P = 0.02). Patients who received a cumulative training of >15 h had significantly lower incidence of peritonitis compared with <15 h (0.26 per year at risk versus 0.32 per year at risk, P = 0.01). The presence of a caregiver and the number of people trained were not significantly associated with peritonitis incidence rate. Training in the immediate 10 days after implantation of the catheter was associated with the highest peritonitis rate (0.32 per year), compared with training prior to catheter implantation (0.28 per year) or >10 days after implantation (0.23 per year). More experienced centers had a lower risk for the first peritonitis (P = 0.003). CONCLUSIONS: This is the first study to analyze the association between training characteristics and outcomes in a large cohort of PD patients. Low training time (particularly <15 h), smaller center size and the timing of training in relation to catheter implantation were associated with a higher incidence of peritonitis. These results support the recommendation of a minimum amount of training hours to reduce peritonitis incidence regardless of the number of hours trained per day.

Sources of variation in estimates of lean body mass by creatinine kinetics and by methods based on body water or body mass index in patients on continuous peritoneal dialysis.

OBJECTIVE: We identified factors that account for differences between lean body mass computed from creatinine kinetics (LBM(cr)) and from either body water (LBM(V)) or body mass index (LBM(BMI)) in patients on continuous peritoneal dialysis (CPD). DESIGN: We compared the LBM(cr) and LBM(V) or LBM(BMI) in hypothetical subjects and actual CPD patients. PATIENTS: We studied 439 CPD patients in Albuquerque, Pittsburgh, and Toronto, with 925 clearance studies. INTERVENTION: Creatinine production was estimated using formulas derived in CPD patients. Body water (V) was estimated from anthropometric formulas. We calculated LBM(BMI) from a formula that estimates body composition based on body mass index. In hypothetical subjects, LBM values were calculated by varying the determinants of body composition (gender, diabetic status, age, weight, and height) one at a time, while the other determinants were kept constant. In actual CPD patients, multiple linear regression and logistic regression were used to identify factors associated with differences in the estimates of LBM (LBM(cr)LBM(V). The differences in determinants of body composition between groups with high versus low LBM(cr) were similar in hypothetical and actual CPD patients. Multivariate analysis in actual CPD patients identified serum creatinine, height, age, gender, weight, and body mass index as predictors of the differences LBM(V)-LBM(cr) and LBM(BMI)-LBM(cr). CONCLUSIONS: Overhydration is not the sole factor accounting for the differences between LBM(cr) and either LBM(V) or LBM(BMI) in CPD patients. These differences also stem from the coefficients assigned to major determinants of body composition by the formulas estimating LBM.

Effects of an intervention to improve communication about end-of-life care among African Americans with chronic kidney disease.

The prevalence of and mortality from chronic kidney disease (CKD) are high among African Americans. Interventions to improve knowledge of the likely illness course and the benefits and risks of life-sustaining treatment at the end-of-life are needed for African Americans with CKD and their surrogate decision makers. Nineteen African Americans with stage 5 CKD and their surrogates were randomized to either patient-centered advance care planning (PC-ACP) or usual care. PC-ACP dyads showed greater improvement in congruence in end-of-life treatment preferences (p < .05) and higher perceived quality of communication (p < .05) than do control dyads, but the two groups did not differ on other primary outcomes or acceptability measures, such as perceptions of cultural appropriateness. At posttest, 80% of patients in the intervention group reported that they would choose to continue all life-sustaining treatments in a situation of a low chance of survival, whereas 28.6% of patients in the control group reported that they would make that choice. At posttest, 90% of patients in the intervention group reported that they would choose to undergo cardiopulmonary resuscitation even if the chance of surviving the attempt would be low, whereas 57% of patients in the control group reported that they would make that choice. PC-ACP can be effective in improving patient and surrogate congruence in end-of-life treatment preferences. However, the results suggest a need for further improvements in the intervention to enhance cultural appropriateness for African Americans with CKD.

Characteristics of depression in hemodialysis patients: symptoms, quality of life and mortality risk.

BACKGROUND: Depression is often underrecognized in patients with end-stage renal disease. We interviewed outpatients at an urban dialysis facility using a criterion-based case-finding instrument to assess the rates, clinical correlates and outcomes of depression. METHODS: The Primary Care Evaluation of Mental Disorders Mood Module and the nine-item Patient Health Questionnaire were used to assess depression. We measured health-related quality of life using the Kidney Disease and Quality of Life Short Form, and medical comorbidities were measured using the Charlson Comorbidity Index. We compared the sociodemographic and clinical characteristics and health-related quality of life of depressed and nondepressed patients using t tests and the chi-square test, and we used a Cox regression model to test the relationship between depression and mortality. RESULTS: We interviewed 62 patients and followed them for a mean of 29 months (range, 0.1-36). Seventeen (28%) had major or minor depression. Depressed patients were younger and had lower health-related quality of life than did nondepressed patients. Depression predicted mortality (HR=4.1, 95% CI=1.5-32.2, P<.05) after adjusting for age, gender, race, medical comorbidities, albumin, kt/V and/or the presence of diabetes. CONCLUSIONS: Depression is common and associated with decreased health-related quality of life and increased mortality in hemodialysis patients. Clinical trials are necessary to examine whether treatment of depression can improve these outcomes.

The effect of coronary angiography on residual renal function in patients on peritoneal dialysis.

BACKGROUND: The risk of intravascular radiocontrast to residual renal function (RRF) in patients on peritoneal dialysis (PD) remains largely unknown. HYPOTHESIS: This study sought to estimate the effect of coronary angiography on RRF in patients on PD. METHODS: All patients at the VA Pittsburgh Healthcare System and University of Pittsburgh who underwent coronary angiography between 1993 and 2005 while on PD and who had RRF measured prior to angiography were identified retrospectively. For patients without a postprocedure RRF recorded, medical records were reviewed to determine whether anuria had developed. The longer-term rate of loss of RRF among cases was compared with a composite rate of decline in RRF among cases before angiography and matched controls. RESULTS: Twenty-nine patients with a mean preprocedure RRF of 4.4+/-3.2 ml/min/1.73m(2) were evaluated. Of these patients, 23 (79%) had postangiography RRF assessments (mean clearance 3.4+/-3.0 ml/min/1.73m(2)). One of the remaining six patients definitely became permanently anuric following angiography, one was lost to follow-up, and there was no postprocedure RRF assessment in four others. The rate of decline in RRF in the cases was similar to the composite rate (0.07 ml/min/1.73m(2)/month vs. 0.09 ml/min/1.73m(2)/month, p=0.53) CONCLUSION: The risk for permanent anuria in patients on PD undergoing coronary angiography appears to be quite small. Patients who do not develop anuria following coronary angiography have the same gradual rate of loss of RRF as other patients on PD. Providers should be vigilant in protecting RRF in patients on PD undergoing coronary angiography.

The relationship between symptoms, depression, and quality of life in peritoneal dialysis patients.

Measurement of patient outcome by mental and social indexes such as quality of life (QOL) in addition to survival is a growing trend. We examined the feasibility of using a single global QOL question in peritoneal dialysis (PD) patients. We also examined the relationship that QOL has with uremic symptoms and depression in these patients. During a clinic visit, each PD patient completed a single-question QOL measure (0-10 scale, 10 being best). Patients' symptoms were assessed using a 10-symptom checklist, with each symptom scored on a Likert scale of 0 (none) to 5 (severe). We evaluated for depression using two questions from the Primary Care Evaluation of Mental Disorders. Serum albumin, hemoglobin, and phosphorus were obtained, but only phosphorus was associated with QOL on univariate analysis (p = 0.05) and therefore included in the multivariate model. Results (checklist score, depression, phosphorus, age, diabetes, and race) were analyzed using a sequential multivariate analysis with QOL as the dependent variable. The study population consisted of 64 PD patients [mean age: 47 +/- 16 years; 25% black; 23% with diabetes; 31% incident (< or =3 months)]. The median score on the single QOL question was 7 (range: 1-10). Patients scored a median of 9 (range: 0-31) out of 50 on the total symptom checklist. Among responding patients, 34% answered yes to at least one depression question. The sequential incremental r2 values associated with a poorer QOL were higher checklist score (r2 = 0.16, p < 0.02), presence of depression (r2 = 0.13, p < 0.00002), younger age (r2 = 0.06, p < 0.03), and presence of diabetes (r2 = 0.04, p < 0.05). In this model, PO4 and race were nonsignificant. Total r2 in the model was 0.48. The single measure of QOL, the checklist score, and the depression screening score were simple and easy to obtain during a routine clinic visit. We conclude that physical symptoms and depression are strongly associated with a simple single measure of QOL. The extent to which symptoms and depression can be improved by clinical intervention, and the subsequent effect on quality of life and survival, should be examined in longitudinal studies.

A Syllabus for Teaching Peritoneal Dialysis to Patients and Caregivers.

Being aware of controversies and lack of evidence in peritoneal dialysis (PD) training, the Nursing Liaison Committee of the International Society for Peritoneal Dialysis (ISPD) has undertaken a review of PD training programs around the world in order to develop a syllabus for PD training. This syllabus has been developed to help PD nurses train patients and caregivers based on a consensus of training program reviews, utilizing current theories and principles of adult education. It is designed as a 5-day program of about 3 hours per day, but both duration and content may be adjusted based on the learner. After completion of our proposed PD training syllabus, the PD nurse will have provided education to a patient and/or caregiver such that the patient/caregiver has the required knowledge, skills and abilities to perform PD at home safely and effectively. The course may also be modified to move some topics to additional training times in the early weeks after the initial sessions. Extra time may be needed to introduce other concepts, such as the renal diet or healthy lifestyle, or to arrange meetings with other healthcare professionals. The syllabus includes a checklist for PD patient assessment and another for PD training. Further research will be needed to evaluate the effect of training using this syllabus, based on patient and nurse satisfaction as well as on infection rates and longevity of PD as a treatment.

Prevalence and correction of 25(OH) vitamin D deficiency in peritoneal dialysis patients.

BACKGROUND: Peritoneal dialysis (PD) patients are at risk for 25(OH) vitamin D deficiency due to effluent loss in addition to traditional risk factors. OBJECTIVES: To measure 25(OH) vitamin D deficiency in prevalent PD patients, to evaluate a replacement dose, and to determine the effects of correction. METHODS: 25(OH) vitamin D levels were drawn on prevalent PD patients. Patients deficientin 25(OH) vitamin D were given ergocalciferol, 50000 IU orally once per week for 4 weeks. Patients scored muscle weakness, bone pain, and fatigue on a scale of 0 (none) to 5 (severe). Serum calcium, phosphate, parathyroid hormone (PTH), and 25(OH) vitamin D, and 1,25(OH)2 vitamin D levels were obtained before and after treatment. RESULTS: 25(OH) vitamin D levels were measured in 29 PD patients. Deficiency (<15 ng/mL) was found in 28/29 (97%); 25/29 (86%) had undetectable levels (<7 ng/mL). One course of ergocalciferol corrected the deficiency in all but 1 patient, who required a second course. Scores for muscle weakness and bone pain fell from pre- to posttreatment (p < 0.001). 1,25(OH)2 vitamin D levels rose post ergocalciferol (from 20 to 26 pg/mL, n = 20, p = 0.09). Serum calcium, phosphate, and PTH levels did not change with ergocalciferol. CONCLUSIONS: Most PD patients had marked 25(OH) vitamin D deficiency, which was readily and safely corrected with one course of 50000 IU ergocalciferol, having no effect on serum calcium, phosphorus, or PTH, but complaints of muscle weakness and bone pain decreased. A prospective, placebo-controlled double-blinded study is needed to determine whether replacement of 25(PH) vitamin D is beneficial in PD patients.

A preliminary study of PDA-based dietary self-monitoring in hemodialysis patients.

OBJECTIVE: The purpose of this study was to pilot test an intervention to enhance the adherence of study participants to the hemodialysis dietary regimen. DESIGN: A single case study design was used to examine the potential effectiveness of the intervention over a 4-month period of time. SETTING: A dialysis center in southwestern Pennsylvania. PATIENTS: Of the five individuals entered into the study, one was male and four were female, four were black, and one was white. Participants were 63 to 70 years of age, and had been receiving dialysis for a median of 36 months (range, 18 to 84 months). INTERVENTION: The intervention included counseling to enhance self-efficacy, by a renal dietitian, paired with personal digital assistant-based dietary self-monitoring. Participants met twice per week with interventionists during the first 6 weeks, weekly during the second 6-week period, and biweekly in the final 4-week period. MAIN OUTCOME MEASURES: Monthly laboratory data regarding serum albumin, potassium, and phosphorus levels; Kt/V; and data on average monthly interdialytic weight gain were abstracted from the participants' medical records. C-reactive protein level was determined at baseline and at 4 months. RESULTS: Four of five study participants had an increase in serum albumin level from baseline to their final measurement, and one participant maintained a stable albumin level. Four of five participants also experienced a small increase in serum phosphorus level. Mixed results were obtained with regard to serum potassium and average monthly interdialytic weight gain. CONCLUSIONS: Because of the small sample and single case study design, caution must be used in drawing firm conclusions from this study. Data suggest that the intervention may result in improved dietary intake and improved serum albumin levels. With increased dietary intake, serum phosphorus levels may increase. Additional research is needed to determine the potential efficacy and cost-effectiveness of this intervention for improving dietary adherence.

Albumin at the start of peritoneal dialysis predicts the development of peritonitis.

BACKGROUND: Both peritonitis and serum albumin level are associated with morbidity and mortality in peritoneal dialysis (PD) patients. Severe cases of peritonitis result in hypoalbuminemia. However, it is not clear whether hypoalbuminemia predicts the development of peritonitis. METHODS: We performed a retrospective analysis of a prospectively collected database from six centers in western Pennsylvania and West Virginia. Incident PD patients with a Charlson Comorbidity Index (CCI) score at the start of PD therapy and serum albumin level measured within 30 days of initiation were selected. Poisson regression was used to analyze predictors of peritonitis. RESULTS: Three hundred ninety-three patients had a CCI score and serum albumin level measured at the start of PD therapy. Overall peritonitis rate was 0.65 episodes/dialysis-year. Significant univariate predictors were albumin level (rate ratio [RR], 0.79 per 1-g/dL [10-g/L] increase; 95% confidence interval [CI], 0.65 to 0.95; P = 0.015), male sex (P = 0.003), and being dialyzed in the Veterans Administration (RR, 1.97; 95% CI, 1.48 to 2.62; P < 0.001) or other center (RR, 1.68; 95% CI, 1.92 to 5.62; P < 0.001). Although CCI score correlated inversely with albumin level (r = -0.305; P < 0.001), CCI score was only marginally predictive of peritonitis (P = 0.068). In multivariate analysis, predictors were albumin level (RR, 0.74; 95% CI, 0.31 to 1.75; P = 0.002) and race (RR, 1.36; P = 0.024). Patients with an initial serum albumin level less than 2.9 g/dL (29 g/L) had a peritonitis rate of 1.5 episodes/dialysis-year compared with 0.6 episodes/dialysis-year for patients with an initial serum albumin level of 2.9 g/dL or greater (P < 0.001). CONCLUSION: Hypoalbuminemia at the start of PD therapy is an independent predictor of subsequent peritonitis. Intervention studies to decrease peritonitis risk in this high-risk subset of patients are needed.

Ethical issues of compliance/adherence in the treatment of hypertension.

The ethics of compliance suggests a conflict within the definition of compliance. Evidence-based medicine appears to provide clear pathways for clinical decisions, but, usually, the patient is not a part of the decision-making process. Physicians often develop a treatment plan and then attempt to make the therapy acceptable to the patient to achieve compliance. Interventions are tested to change patient behavior, but few are designed to consider the patient's point of view. Some suggest that the ideal patient is passive and obedient. However, few patients are either. The individual's perspective and goals most certainly affect adherence with a medical treatment and cannot be ignored. This article reviews the ethics of compliance/adherence issues. Future research of compliance might be improved if studies were designed to include patient preference in a partnership with physicians.

Comparison of the Charlson Comorbidity Index and the Davies score as a predictor of outcomes in PD patients.

BACKGROUND: Comorbidity is a strong predictor and confounds many studies of outcomes. Previous studies have shown that the Charlson Comorbidity Index (CCI) and the Davies score predict mortality in peritoneal dialysis (PD) patients. However, there are few data on the comparison of comorbidity scores. OBJECTIVE: To compare the CCI (combines comorbidity and age) and Davies score (comorbidity score without age) to see if one score was superior to the other in predicting outcomes. DESIGN: Prospective database study. SETTING: Seven dialysis centers in Western Pennsylvania. PARTICIPANTS: 415 incident PD patients, starting PD from 1/1/90 to 2/1/00. MEASUREMENTS: The CCI and Davies score calculated at the start of PD; serum albumin levels and demographics at the start of PD; total hospitalizations and mortality, collected prospectively. RESULTS: The correlation between CCI and Davies was 0.80, p < 0.0001. The CCI was inversely correlated with serum albumin (-0.31, p < 0.0001). Davies was significantly correlated with age (0.32, p < 0.0001) and inversely correlated with albumin (-0.27, p < 0.0001). The CCI alone was a stronger predictor than Davies alone (score by best subsets regression 49.6 vs 42.0, p = 0.0058). The CCI and Davies with age appeared to be equivalent models of survival (49.61 vs 49.64). The best predictive models were CCI and initial albumin, or Davies, age, and initial albumin. Both CCI and Davies were predictors of hospitalization rates, but the model with the Davies score was better (Akaike information criterion 799.2 vs 850.2). The best predictive model was Davies, albumin, age, and race. CONCLUSIONS: Both comorbidity scores were significant predictors of outcomes, with CCI the stronger predictor for mortality, but the Davies was a stronger predictor of hospitalizations. One or both should be done at the start of dialysis to predict outcome.

Staphylococcus aureus prophylaxis and trends in gram-negative infections in peritoneal dialysis patients.

OBJECTIVE: To examine gram-negative exit-site infection and peritonitis rates before and after the implementation of Staphylococcus aureus prophylaxis in peritoneal dialysis (PD) patients. DESIGN: Prospective data collection with periodic implementation of protocols to decrease infection rates in two PD programs. PATIENTS: 663 incident patients on PD. INTERVENTIONS: Implementation of S. aureus prophylaxis, beginning in 1990. MAIN OUTCOME MEASURES: Rates of S. aureus, gram-negative, and Pseudomonas aeruginosa exit-site infections and peritonitis. RESULTS: Staphylococcus aureus exit-site infection and peritonitis rates fluctuated without significant trends during the first decade (without prophylaxis), then began to decline during the 1990s subsequent to implementation of prophylaxis, reaching levels of 0.02/year at risk and zero in the year 2000. Gram-negative infections fell toward the end of the 1980s, due probably to the implementation of better connectology. However, there have been no significant changes for the past 6 years. There was little change in P. aeruginosa infections over the entire time period. Pseudomonas aeruginosa is now the most common cause of catheter infection and catheter-related peritonitis. CONCLUSIONS: Prophylaxis against S. aureus is highly effective in reducing the rate of S. aureus infections but has no effect on gram-negative infections. Pseudomonas aeruginosa is now the most serious cause of catheter-related peritonitis.

The effect of depressive symptoms on survival in peritoneal dialysis patients.

OBJECTIVE: There is little information on the relationship between depressive symptoms and survival in peritoneal dialysis (PD) patients. We examined whether a single measurement of depressive symptoms using a simple self-administered tool predicts survival. DESIGN: Screening test of depressive symptoms as a predictor of outcome. SETTING: Three dialysis centers in Southwestern Pennsylvania. PARTICIPANTS: 66 adult PD subjects were screened in 1997-1998 for depression using the Zung scale. MAIN OUTCOME MEASURES: Baseline data collection included assessments of comorbidity, residual renal function, total Kt/V, nPNA, previous renal transplant, and serum albumin. Outcomes were collected prospectively after completion of the depression survey to 12/01. Cox regression analysis of patient survival was performed using all cofactors with p < 0.05 on univariate analysis. RESULTS: One third of patients had depressive symptoms. Compared to nondepressed patients, depressive symptom patients were older (62.5 vs 52.5 years, p = 0.012), had borderline lower serum albumin levels (3.47 vs 3.70 g/dL, p = 0.058), and were more disabled (Karnofsky score 70 vs 90, p< 0.001), but had similar Kt/V, residual renal function, and previous time on PD at the point of the testing. Using multivariate analysis and controlling for comorbidity (using a measurement that includes diabetes mellitus and age) and serum albumin, the survival of patients with depressive symptoms was significantly reduced compared to nondepressed patients. CONCLUSION: A single measurement of depressive symptoms using a simple self-administered test was an independent predictor of death in a cohort of PD patients, which extends observations in hemodialysis patients. Screening for depressive symptoms should be routine for dialysis patients, and those depressed should have thorough assessment and treatment. Whether treating depression will have an impact on survival is unclear and needs to be studied.

Large body mass index does not predict short-term survival in peritoneal dialysis patients.

OBJECTIVE: Higher than normal body mass index (BMI) is associated with an increased risk of death in the general population. We examined the effect of higher than normal BMI on patient and technique survival in peritoneal dialysis patients (PD), controlling for comorbidity, initial albumin, dialysate-to-plasma ratio of creatinine (D/P(Cr)), and initial urea clearance (Kt/V). DESIGN: Registry database. SETTINGS: Four dialysis centers. PATIENTS: Incident PD patients. METHODS: All data were collected prospectively. Demographics, BMI, serum albumin, D/P(Cr), and comorbidity using the Charlson Comorbidity Index (CCI) were determined at the start of PD. 104 patients with a high BMI (> 27) were matched to a control group of 104 patients with normal BMI (20-27) for age, gender, presence of diabetes, and CCI. Patient and technique survival were compared using Cox proportional hazards model. MAIN OUTCOME MEASURES: Patient and technique survival. RESULTS: The groups were of similar age (56.1 vs 56.7 years), sex (60% males in both groups), race (Caucasian 80% vs 86%), presence of diabetes (40% vs 37%), CCI score (5.4 in both groups), initial albumin (3.6 vs 3.5 g/dL), and D/P(Cr) (0.65 in both groups). Kaplan-Meier survival analysis showed similar 2-year patient survival between large BMI (> 27) and control (20-27) groups (76.6% vs 76.1%). Two-year technique survival was also similar between the two groups (59.7% vs 66.8%). With Cox proportional hazards analysis, BMI was not a predictor of patient mortality or technique survival when controlling for initial albumin, D/P(Cr), and initial Kt/V. CONCLUSIONS: We conclude that a BMI above normal is not associated with any increased or decreased risk of death in patients on PD for 2 years.

Methods to determine drain volume for peritoneal dialysis clearances.

OBJECTIVE: To compare the accuracy and convenience of 3 methods for measuring drain volume for peritoneal dialysis (PD) clearance studies. DESIGN: Prospective comparison of both automated PD (APD) and continuous ambulatory PD (CAPD) clearance study methods. SETTING: Adults > or = 18 years old at 2 dialysis clinics. PATIENTS: 28 PD patients with 43 clearance studies, 15 on CAPD and 28 on APD. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Drain volume was determined by 3 methods for each study: (1) graduate-measured volume using a 2-L graduated cylinder; (2) weighed volume, with and without bag weight, using a digital floor scale or spring scale; (3) cycler-measured volume using the initial drain and ultrafiltration indicated by the cycler, plus the prescribed inflow volume without the last fill. RESULTS: There was no statistically significant difference in volumes using the 3 methods studied (all p > 0.89 for APD, all p > 0.97 for CAPD). Effluent volume was more accurate with the weight of the bag subtracted. CONCLUSION: The most convenient and a precise method for APD is to determine the effluent drain volume using the prescription and total ultrafiltration and initial drain, as measured by the cycler. For CAPD, using the weight of drained bags is accurate but the weight of the empty bag must be subtracted. These approaches have the least risk of exposing staff to body fluids.