Recovery Time after Hemodialysis Is Inversely Associated with the Ultrafiltration Rate.

INTRODUCTION: The present study aimed to determine the variables that are associated with a longer dialysis recovery time (DRT) and to define the relationship that exists between DRT and the ultrafiltration rate (UFR) in prevalent chronic hemodialysis (CHD) patients. METHODS: We studied 210 prevalent CHD of 5 hemodialysis units in Central Italy. Patients were invited to answer to the question: "How long does it take you to recover from a dialysis session?" Answers to this question were subsequently converted into minutes. Demographic, clinical and laboratory parameters were recorded for each patient as well as the UFR (mL/kg/h), the dialysate sodium concentration and temperature. RESULTS: Median DRT was 180 min (60-420). Ninety five (45%) patients had a DRT ≥ the median value. Mean UFR was 9.2 ± 3.0 mL/kg/h. Patients with a lower DRT had a less prevalent disability in the instrumental activities daily living, had a higher UFR, and a lower dialysate temperature, as compared with subjects with higher DRT. According to the logistic regression model, UFR was associated with a DRT below the median (i.e., 180) in the unadjusted model (OR 1.12; 95% CI 1.02-1.23; p = 0.019), after adjusting for age and sex (OR 1.11; 95% CI 1.01-1.22; p = 0.025), and in the fully adjusted model (OR 1.11; 95% CI 1.04-1.22; p = 0.040). UFR increase was associated with increasing probability of DRT below the median (p for trend = 0.035). The highest tertile of DRT was associated with UFR below the mean value (i.e., 9.2 mL/kg/h) in multinomial logistic regression having the lowest DRT tertile as reference. DRT was significantly lower in patients with UFR > 13 mL/kg/h than in patients with UFR 10-13 or < 10 mL/kg/h. CONCLUSION: DRT is inversely associated with UFR in CHD patients. Whether a high UFR should be recommended to reduce the DRT needs to be elucidated through an adequate prospective randomized study.

Prevalence and associated variables of post-dialysis fatigue: Results of a prospective multicentre study.

AIM: The study aims to determine prevalence and severity of PDF and to define its associated variables. METHODS: In five haemodialysis units of northern-centre Italy, patients were regarded to suffer from PDF if they spontaneously offered this complaint when asked the open-ended question: Do you feel better or worse after dialysis? If worse, please specify in which way. A complaint of fatigue would be probed further with questions directed at its duration, frequency and intensity, allowing creation of a fatigue index of severity (one third of the sum of these three parameters, each rated from 1 to 5). Patients were stratified into three groups according the severity of PDF: 1) score = 0; 2) score = 1-3; 3) score > 3. RESULTS: We studied 271 patients: 164 had PDF and 107 did not. PDF patients had significantly longer time of recovery after dialysis (TIRD). TIRD was significantly associated with PDF duration, intensity, and frequency. Patients with PDF were older and had a lower ADL score. At multivariate analysis, PDF was significantly associated with TIRD. In a multivariate model that did not include TIRD, PDF was independently associated with age and ADL. Sixty patients had moderate PDF and 104 had severe PDF. In patients with severe PDF, age and dialytic age were higher, ADL and IADL scores were lower, TIRD was longer and the ultrafiltration rate was lower. At multivariate analysis, PDF severity was independently associated with TIRD. In the model without TIRD, PDF severity was associated with ADL only. CONCLUSION: Post-dialysis fatigue is frequent and associated with age and ADL. Dialytic variables seem unrelated to PDF.

Peritoneal Dialysis Catheter Position Evaluated by Ultrasound: Can it Replace Abdomen X-Ray in Patients Presenting Catheter Misplacement?

Background Malfunction of the peritoneal dialysis catheter is frequently caused by dislocation. The diagnostic approach is classically based on abdomen X-ray together with detailed case history and physical examination. Despite being rarely applied in clinical practice to evaluate catheter misplacement, ultrasound is a noninvasive, radiation-free technique that is potentially useful also to explore reasons for catheter malfunction. Consequently, we aimed to evaluate the diagnostic accuracy of ultrasound to identify peritoneal catheter misplacement. Methods In a multicenter observational blinded study, we compared ultrasound to abdomen X-ray for catheter localization in 93 consecutive peritoneal dialysis patients with dialysate outflow problems enrolled in two nephrology and dialysis units. The position of the catheter was annotated on a standard scheme of nine abdominopelvic regions. The sensitivity, specificity, positive and negative predictive value and Kappa coefficient were calculated. Results Dislocation out of the inferior abdominopelvic regions was present in 19 patients (20 %) at X-ray and 23 patients (25 %) at ultrasound. Correct determination of the position of the catheter in the lower abdomen by ultrasound had a sensitivity of 93 % (95 % CI 84 - 97 %), specificity of 95 % (95 % CI 72 - 100 %), positive predictive value of 99 % (95 % CI 91 - 100 %), negative predictive value of 78 % (95 %CI 56 - 92 %) and Kappa coefficient of 0.82 (95 % CI 0.67 - 0.96). In 10 out of 93 patients (11 %), there was a position mismatch between X-ray and ultrasound in an adjacent abdominopelvic region. Conclusion Our results suggest that abdomen X-ray for the evaluation of peritoneal catheter position can be replaced by ultrasound in experienced hands. This bedside diagnostic procedure might reduce costs, the time necessary for diagnosis and lifetime radiation exposure.

Use of Proton Pump Inhibitors Is Not Associated with Post-Dialysis Fatigue and Time of Recovery after Dialysis in Patients on Maintenance Hemodialysis.

Objectives: To define if the use of proton pump inhibitors (PPI) is associated with PDF prevalence and characteristics and with time of recovery after dialysis in patients on maintenance hemodialysis. Methods: Patients were defined as experiencing PDF if they spontaneously offered this complaint when asked the open-ended question: "Do you feel fatigued after dialysis?". Time of recovery after dialysis (TIRD) was also assessed for each patient. Each patient was invited to rate the intensity, duration and frequency of PDF from 1 to 5. We defined if patients used PPI (no PPI use or PPI use), the type of used PPI, the dose of used PPI, and the duration of the use of PPI (<1 year or ≥1 year). Results: A total of 346 patients were studied: 259 used PPI (55 used omeprazole, 63 esomeprazole, 54 pantoprazole, 87 lansoprazole, and 7 rabeprazole) and 87 did not. Two hundred and thirty-two patients declared PDF and 114 did not. The median [min-max] TIRD was 210 min [0-1440]. The prevalence of PDF in PPI users and PPI non-users was 67% and 68%, respectively (p = 0.878). The median [min-max] TIRD did not differ significantly between PPI users and PPI non-users (180 [0-1440] and 240 [0-1440], respectively; p = 0.871). Median PDF intensity, duration, frequency, and severity did not differ significantly between PPI use and no use. The prevalence of PDF was similar among the different types of PPI use and did not differ with respect to PPI non-users. Duration of PPI exposure was <1 year in 40 patients and ≥1 year in 219 patients. The prevalence of PDF did not differ between the two exposures. The correlation matrix between PPI equivalent dose, PPI treatment duration and PDF frequency, PDF characteristics, and TIRD showed whether there was statistical significance. Conclusions: The use of PPI is not associated with PDF and time of recovery after dialysis in patients on maintenance hemodialysis.

Interdialytic weight gain is not associated with symptoms of depression or apathy in patients on chronic hemodialysis.

PURPOSE: Little is known about the relationships between apathy, depressive symptoms and interdialytic weight gain (IDWG) in patients on chronic hemodialysis. Aim of the present study is to investigate the association between IDWG and symptoms of depression and apathy in hemodialysis patients. METHODS: A total of 139 chronic patients of the HD units between January 2020 and December 2021 were included in the present cross-sectional study. IDWG was calculated as the difference between the pre-HD weight and the weight registered after the previous session; the average of the sessions in a month was registered. Apathy Evaluation Scale (AES) was adopted to evaluate apathy. Depression was assessed by Beck Depression Inventory (BDI). RESULTS: Ninety-three patients had IDWG% ≤ 4 and 46 had an IDWG% > 4. Correlation between IDWG% and BDI as well that between IDWG% and AES were not statistically significant. Median BDI and mean AES did not differ significantly between the groups. In addition, 104 patients had a BDI < 16 and 35 had a BDI ≥ 6. Seventy-five patients had an AES score ≤ 35 and 63 had a AES score > 35. The IDWG (kg) and the IDWG% did not differ significantly between the two groups. CONCLUSION: IDWG is not associated with symptoms of depression or apathy in hemodialysis patients. Thus, these results may question if the use of behavioral intervention aimed at improving motivation is warranted in the hemodialysis population to reduce the IDWG.

Post-dialysis fatigue: Comparison of bicarbonate hemodialysis and online hemodiafiltration.

INTRODUCTION: The present cross-sectional study aimed to compare the prevalence, the characteristics of post-dialysis fatigue and the length of recovery time after hemodialysis in prevalent end-stage renal disease patients (ESRD) receiving bicarbonate hemodialysis (HD) or hemodiafiltration (HDF). METHODS: Patients were suffering from post-dialysis fatigue if they spontaneously offered this complaint when asked the open-ended question: "Do you feel fatigued after dialysis?". Moreover, each patient was invited to rate the intensity, duration, and frequency of post-dialysis fatigue from 1 to 5. In order to assess RECOVERY TIME AFTER DIALYSIS, patients were invited to answer to the following single open-ended question: "How long does it take you to recover from a dialysis session?" FINDINGS: We included 335 patients: 252 received HD and 83 received HDF. Post-dialysis fatigue was present in 204 patients (60.9%). Prevalence of post-dialysis fatigue did not differ significantly between patients on HD (62.3%) and on HDF (56.6%; p = 0.430). Median recovery time after dialysis was 180 min [180-240] and did not differ significantly between the two subgroups (180 min [130-240] and 240 min [120-332] p = 0.671, respectively). Median post-dialysis fatigue intensity, duration, and frequency were 3 [1-5], 3 [1-5], and 4 [1-5] and did not differ significantly between patients on HD and on HDF. At the multivariate analysis, age, ADL and hemoglobin levels were the independent predictors of the HDF treatment. DISCUSSION: Prevalence and characteristics of post-dialysis fatigue do not differ significantly between patients receiving bicarbonate HD or HDF.

Fatigue and apathy in patients on chronic hemodialysis.

INTRODUCTION: This study explores the link between fatigue and apathy in patients on chronic hemodialysis (HD). METHODS: One hundred thirty-nine chronic HD patients underwent the assessment of fatigue, apathy, depression, and their functional status, with the fatigue severity scale (FSS), the Apathy Evaluation Scale (AES), the beck depression inventory (BDI), the activity of daily living (ADL), and instrumental activity of daily living (IADL). RESULTS: Patients with high FSS had a significantly lower ADL and IADL score, higher BDI, Charlson Comorbidity Index, and AES score, and lower serum levels of creatinine, compared to low FSS patients. FSS was highly correlated with the AES, as well as with the BDI and the AES correlates with the BDI. At multiple regression analyses, only apathy and IADL were independent predictor variables of fatigue in HD population. CONCLUSION: Future longitudinal studies could determine if apathy is a causative factor for fatigue manifestation and development in HD patients.

Diagnostic capability of ultrasound in peritoneal catheter malfunction compared to videolaparoscopy.

BACKGROUND: The approach to peritoneal catheter malfunction consists usually in a diagnostic and therapeutic sequence of laxative prescription, abdominal radiography, brushing of the catheter, guide-wire manipulation or fluoroscopy and in the end of a videolaparoscopy (VLS) rescue intervention. Ultrasound (US) is able to find out major causes of peritoneal catheter malfunction, however without a clearly defined diagnostic value. The aim of the study was to validate the diagnostic capability of US in catheter malfunction compared to the diagnostic reference of VLS. METHODS: US scans of the subcutaneous and intraperitoneal segment of the catheter were performed prior to a VLS intervention in 40 adult patients presenting persistent catheter malfunction within a prospective multicentre study. Laxative prescription and brushing of the catheter lumen were undertaken prior to US scan. US diagnosis was compared to the corresponding at VLS, kappa coefficient calculated and the causes of mismatch analysed. RESULTS: In US, causes of persistent malfunction were catheter dislocation combined with omental wrapping in 21 cases, omental wrapping without dislocation in 11 cases, dislocation only in 4 cases, adherences to non-omental structures in 3 cases and entrapment in the lateral inguinal fossa in 1 case. The US diagnosis corresponded to the respective at VLS in 36 of 40 cases, resulting in a kappa coefficient of 0.89 (95% CI: 0.78-1.00). The discrepancies were due to improper visualization of the catheter between omentum and intestinal loops, resulting in an erroneous US diagnosis of omental wrapping. CONCLUSIONS: This study suggests that US might have a pivotal role in the diagnostic approach to peritoneal catheter dysfunction.

Giant mesenteric cyst of mesothelial origin in a haemodialysis patient with previous peritoneal dialysis therapy.

A 55-year-old female haemodialysis patient presented progressive abdominal liquid formation after having been excluded from peritoneal dialysis therapy because of recurrent peritonitis. Ultrasound was suspicious for ascites secondary to sclerosing peritonitis. Computed tomography revealed a thin-walled mesenteric cyst extending from the epigastric to the pelvic region. The cyst was excised incompletely as extensive adhesions were present. Histology was consistent with a mesothelial cyst of inflammatory origin. Three months after surgery, ultrasound detected a local recurrence at the descending colon. This case emphasizes the relation between mesenteric cyst, persistent inflammatory status and preceding peritoneal dialysis complicated by peritonitis.

Dietary Daily Sodium Intake Lower than 1500 mg Is Associated with Inadequately Low Intake of Calorie, Protein, Iron, Zinc and Vitamin B1 in Patients on Chronic Hemodialysis.

Background: To measure daily sodium intake in patients on chronic hemodialysis and to compare the intake of nutrients, minerals, trace elements, and vitamins in patients who had a daily sodium intake below or above the value of 1500 mg recommended by the American Heart Association. Methods: Dietary intake was recorded for 3 days by means of 3-day diet diaries in prevalent patients on chronic hemodialysis. Each patient was instructed by a dietitian on how to fill the diary, which was subsequently signed by a next of kin. Results: We studied 127 patients. Mean sodium intake (mg) was 1295.9 ± 812.3. Eighty-seven (68.5%) patients had a daily sodium intake <1500 mg (group 1) and 40 (31.5%) ≥ 1500 mg (group 2). Correlation between daily sodium intake and daily calorie intake was significant (r = 0.474 [0.327 to 0.599]; p < 0.0001). Daily calorie intake (kcal/kg/day) was lower in group 1 (21.1 ± 6.6; p = 0.0001) than in group 2 (27.1 ± 10.4). Correlation between daily sodium intake and daily protein intake was significant (r = 0.530[0.392 to 0.644]; p < 0.0001). The daily protein intake (grams/kg/day) was lower in group 1 (0.823 ± 0.275; p = 0.0003) than in group 2 (1.061 ± 0.419). Daily intake of magnesium, copper, iron, zinc, and selenium was significantly lower in group 1 than in group 2. Daily intake of vitamin A, B2, B3, and C did not differ significantly between group 1 and group 2. Daily intake of vitamin B1 was significantly lower in group 1 than in group 2. Significantly lower was, in group 1 than in group 2, the percentage of patients within the target value with regard to intake of calories (11.5% vs. 37.5%; p = 0.001) and proteins (9.2% vs. 27.5%; p = 0.015) as well as of iron (23% vs. 45%; p = 0.020), zinc (13.8% vs. 53.8%; p = 0.008) and vitamin B1 (8.1% vs. 50%; p < 0.001). Conclusion: A low daily intake of sodium is associated with an inadequately low intake of calorie, proteins, minerals, trace elements, and vitamin B1. Nutritional counselling aimed to reduce the intake of sodium in patients on chronic hemodialysis should not disregard an adequate intake of macro- and micronutrients, otherwise the risk of malnutrition is high.

Intensity, Duration, and Frequency of Post-Dialysis Fatigue in Patients on Chronic Haemodialysis.

BACKGROUND: Although frequent and debilitating, little is known about the characteristics of post-dialysis fatigue (PDF). OBJECTIVE: To characterise the intensity, duration and frequency of PDF and the associated variables in patients on chronic haemodialyses. DESIGN: Prospective, observational and multicenter study. PATIENTS: We studied 271 patients. MEASUREMENTS: Patients were considered to be suffering from PDF if they spontaneously offered this complaint when asked the open-ended question: "Do you feel fatigued after dialysis? Then, each patient was invited to rate the intensity, duration and frequency of PDF from 1 to 5. RESULTS: One hundred sixty-four patients (60.5%) had PDF. The median [95% confidence interval (CI)] scores of PDF intensity, duration and frequency were 3 (3-4), 3 (3-4) and 4 (4-4), respectively. The median (95% CI) of the sum of the scores (Sum Score) of PDF intensity, duration and frequency was 11 (10-12). Seventy four patients had a Sum Score ≥ 12. Using multiple regression analysis, PDF intensity was associated with dialytic age and ultrafiltration rate (UFR), PDF duration with dialytic age, while PDF fatigue frequency was associated with height. The Sum Score was associated with dialytic age and recovery time and negatively associated with daily activity, height and UFR (ml/kg/h). CONCLUSION: The intensity, duration and frequency of PDF are high in a large percentage of patients, suggesting that PDF is an intense event in terms of quantity and quality. Understanding the relationship between the variables associated with PDF and its intensity, duration and frequency may help better understand the underlying mechanisms of this burdensome condition.

Prevalence and Severity of Postdialysis Fatigue Are Higher in Patients on Chronic Hemodialysis With Functional Disability.

The aim of the present study was to determine the intensity, duration, frequency and prevalence of postdialysis fatigue (PDF) in patients on chronic hemodialysis (PCD) with and without functional disability. Patients underwent assessment of functional ability by the Katz ADL (activity daily living) questionnaire and the Lawton and Brody scale for the instrumental activity daily living (IADL) fatigue using the SF-36 Vitality Subscale, comorbidity through the Charlson comorbidity score index (CDI), and time of recovery after hemodialysis (TIRD). We studied 271 PCD. ADL and IADL disabilities were present in 75 (27.6%) and 168 (62%) patients, respectively. Patients with ADL disability were significantly older and showed higher CDI scores, and lower levels of serum albumin and Kt/V. Prevalence of PDF was significantly higher in patients with ADL disability as well as its severity, intensity, duration and frequency. Patients with IADL disability were significantly older, had a higher CCI score, had lower levels of serum albumin and Kt/V, and had a higher severity, intensity, duration and frequency of PDF. At multivariate regression analysis, ADL disability was positively associated with age, prevalence and severity of PDF, and dialysate temperature and inversely associated with serum albumin levels. IADL disability was instead positively associated with age and dialysate temperature and inversely associated with serum albumin levels. In conclusion, prevalence and severity of PDF are significantly higher in PCD with ADL disability than in those without it. This knowledge may have important implications for the development of interventions to reduce PDF in PCD.

[Trend in PD in non-pediatric public centers in Italy: results of the 2010 GSDP-SIN census and comparison with the 2008 and 2005 censuses]. / Andamento della DP in Italia nei centri pubblici non pediatrici: Risultati del censimento GSDP-SIN 2010 e confronto con i censimenti 2008 e 2005.

The 2010 Italian Society of Nephrology Peritoneal Dialysis Study Group (GSPD-SIN) census (Cs-10) involved the 224 Centers performing PD in Italy. PD was used as 1st treatment in 23.3% (1429/4695) of pts (Cs-08:22.8%; Cs-05:24.2%), with 53.4% of them using CAPD. The use of incremental CAPD increased in Cs-10 (Cs-10:35.3%; Cs-08:25.7%; Cs-05:13.6%; p<0.0001). The number of prevalent pts was 4,222 (Cs-10:16.6%; Cs-08:16.6%; Cs-05:16.8%; p=NS), 45.7% of whom were on CAPD; 24.4% (Cs-08:21.8%; p<0.05) required assistance (family member:80.6%; caregiver:12.6%; nurse: 3.0%; RSA:3.4%). In Cs-10 the PD out rate (1,354 pts, of whom ep/100pt-yrs for drop-out: 12.4; death: 12.9; Tx: 7.5) was not different to previous years. The peritonitis rate was 0.30 ep/yr/pt, 18.5% of which with negative culture. There were 44 episodes of EPS in the period 2009-10 (0.53 ep/100yrs); while in the previous 5-year period there were 146 (0.70 ep/100pt-yrs). PET is performed by 98% of the centers, mostly using 2.27% (70.5%). Home visits are carried out by 59.1% of the centers. If regular (8.9% of the centers), they are associated with fewer ep/mth of peritonitis (61.2 vs 38.8) and lower drop-out (8.6 vs 12.8 ep/100 pt/yr - p<0.05) Cs-10 confirms the good results PD is having in the Centers that use it. Incremental CAPD and assisted PD are increasing. EPS remains a rare event. Standard PET is the most frequently-used evaluation of the peritoneal membrane. Though home visits are associated with lower peritonitis and drop-out rates, they are carried out regularly by a minority of the Centers.

Dietary intake of trace elements, minerals, and vitamins of patients on chronic hemodialysis.

PURPOSE: We aimed to estimate dietary intakes of trace elements, minerals, and vitamins in hemodialysis patients (HDP) of three centers in one metropolitan and two urban areas of Italy. METHODS: Daily dietary intake was assessed using a 3-day diet diary in 128 HDP. RESULTS: Mean daily intakes of trace elements were as follows: zinc, 7.6 ± 5.4 mg; copper, 14.3 ± 11.8 mg; selenium, 28.3 ± 18.1 µg; and iron, 7.2 ± 4.1 mg (7.8 ± 2.6 mg in women, 6.9 ± 2.4 mg in men). The distribution of patients by daily intakes of trace elements showed most were under the recommended values, with the exception of copper intake, which was much higher. Mean daily intakes of minerals were as follows: magnesium, 174.4 ± 94.3 mg; phosphorus, 842.6 ± 576.8 mg; calcium, 371.8 ± 363.7 mg; potassium, 1,616.2 ± 897.3 mg; and sodium, 1,350 ± 1,281 mg. Mean daily intakes of vitamins were as follows: vitamin A, 486.1 ± 544.6 µg; vitamin B1, 0.86 ± 0.7 mg; vitamin B2, 1.1 ± 0.7 mg; vitamin B3, 13.3 ± 8.1 mg; vitamin C, 47.8 ± 50.3 mg; and vitamin E, 9.5 ± 3.6 mg. The distribution of patients by daily intakes of vitamins showed most were under the recommended values. Daily intakes of trace elements and vitamins were similar among the three centers and did not differ between dialysis and non-dialysis days. CONCLUSIONS: Many HDP have daily dietary intakes of trace elements and vitamins below the recommended values, whereas the intake of copper is much higher.

Videolaparoscopic catheter placement reduces contraindications to peritoneal dialysis.

BACKGROUND: Videolaparoscopy is considered the reference method for peritoneal catheter placement in patients with previous abdominal surgery. The placement procedure is usually performed with at least two access sites: one for the catheter and the second for the laparoscope. Here, we describe a new one-port laparoscopic procedure that uses only one abdominal access site in patients not eligible for laparotomic catheter placement. METHOD: We carried out one-port laparoscopic placement in 21 patients presenting contraindications to blind surgical procedures because of prior abdominal surgery. This technique consists in the creation of a single mini-laparotomy access through which laparoscopic procedures and placement are performed. The catheter, rectified by an introducer, is inserted inside the port. Subsequently, the port is removed, leaving the catheter in pelvic position. The port is reintroduced laterally to the catheter, confirming or correcting its position. Laparotomic placement was performed in a contemporary group of 32 patients without contraindications to blind placement. Complications and long-term catheter outcome in the two groups were evaluated. RESULTS: Additional interventions during placement were necessary in 12 patients of the laparoscopy group compared with 5 patients of the laparotomy group (p = 0.002). Laparoscopy documented adhesions in 13 patients, with need for adhesiolysis in 6 patients. Each group had 1 intraoperative complication: leakage in the laparoscopy group, and intestinal perforation in the laparotomy group. During the 2-year follow-up period, laparoscopic revisions had to be performed in 6 patients of the laparoscopy group and in 5 patients of the laparotomy group (p = 0.26). The 1-year catheter survival was similar in both groups. Laparoscopy increased by 40% the number of patients eligible to receive peritoneal dialysis. CONCLUSIONS: Videolaparoscopy placement in patients not eligible for blind surgical procedures seems to be equivalent to laparotomic placement with regard to complications and long-term catheter outcome. The number of patients able to receive peritoneal dialysis is substantially increased.

Peritoneal dialysis access: open versus laparoscopic surgical techniques.

AIM: To outline pros and cons with the open and laparoscopic techniques when placing peritoneal dialysis (PD) catheters. BACKGROUND: Controversy exists regarding which technique, the open and laparoscopic, if any, is superior to the other. In addition, there is the question of which approach is best in rescuing malfunctioning PD catheters. RESULTS: Rather than promoting one doctrine fits all, philosophically, doing the right thing for the patient by specific criteria is ethically the better model. These specific selection criteria include patient characteristics, the team's skills and knowledge and institutional resources and commitment. Also, the sophistication of a PD unit for training and monitoring of patients is crucial for successful outcomes. Open paramedian and two laparoscopic approaches are described in detail, outlining advantages and disadvantages of each, with suggestions when one method is preferred. CONCLUSIONS: In general, the laparoscopic technique is associated with longer operative times, higher costs and the need to utilize general anesthesia. It is, however, the preferred method when rescuing malfunctioning catheters and may increase the PD patient population in patients with previous abdominal surgeries. The dialysis access surgeon should be familiar with both open and laparoscopic techniques and appropriately choose the ideal method based upon the individual patient and institutional resources.

Dietary intake of macronutrients and fiber in Mediterranean patients on chronic hemodialysis.

BACKGROUND: We aimed to measure the dietary intake of calories, proteins, carbohydrates, lipids and fiber in patients on chronic hemodialysis (HD) at 3 centers in 1 metropolitan and 2 urban areas of Italy, and to evaluate whether it met the dietary guidelines for cardiovascular risk reduction. METHODS: Daily dietary intake was assessed through a 3-day diet diary in 128 HD patients at the hemodialysis units of the Catholic University of Rome, Hospital A. Murri of Jesi and Hospital Principe di Piemonte of Senigallia, Italy. RESULTS: Mean dietary calorie and protein intakes were 22.9 ± 9.1 kcal/kg per day and 0.95 ± 0.76 g protein/kg per day, respectively. Daily carbohydrate and lipid intakes as a percentage of total calorie intake were 51.8% ± 8.9% and 32.1% ± 7.1%. Mean daily dietary cholesterol intake was 206.6 ± 173.6 mg. Mean daily dietary intakes of omega-3 and omega-6 fatty acids were 0.49 ± 0.28 g and 5.1 ± 2.5 g, respectively, while the mean ratio of omega-6 to omega-3 intake was 11.5 ± 4.8. Forty-eighty percent of patients had an omega-6 to omega-3 ratio =10. Mean daily dietary intakes of saturated fatty acids (SFAs), monounsaturated fatty acids and polyunsaturated fatty acids were 5.5 ± 3.3 g, 28.9 ± 9.1 g and 3.1 ± 1.7 g, respectively. Ninety-six percent of HD patients had an SFA intake <10% of total calories. Most unsaturated fatty acids intakes were under the value of =30%. Mean daily dietary fiber intake was 11.8 ± 6.1 g. CONCLUSION: In HD patients from a Mediterranean country (Italy), daily intakes of calories, proteins and fiber were lower than the recommended values, whereas the intake of lipids was closer to being adequate.

The peritoneal dialysis catheter.

The results obtained from the positioning and management of the catheter for peritoneal dialysis depend on the techniques used, but also and above all, on the experience of the practitioners. A comparison between practitioners may help to change their convictions, as well as to further improve results, in the interests of patient welfare. This is the aim of these Best Practice Guidelines..

Peritoneal ultrafiltration in patients with advanced decompensated heart failure.

The aim of the Best Practice guidelines on peritoneal ultrafiltration (UF) in patients with treatment-resistant advanced decompensated heart failure (TR-AHDF) is to achieve a common approach to the management of decompensated heart failure in those situations in which all conventional treatment options have been unsuccessful, and to stimulate a closer cooperation between nephrologists and cardiologists. The standardization of the case series of different centers would allow a better definition of the results published in the literature, without which they are nothing more than anecdotes. TR-AHDF is characterized by the persistence of severe symptoms even when all possible pharmacological and surgical options have been exhausted. These patients are often treated with methods that allow extracorporeal UF - slow continuous ultrafiltration (SCUF) and continuous renal replacement therapy (CRRT) - which have to be performed in hospital facilities. Peritoneal ultrafiltration (PUF) can be considered a treatment option in patients with TR-AHDF when, despite the fact that all treatment options have been used, patients meet the following criteria: • stage D decompensated heart failure (ACC/AHA classification); • INTERMACS level 4 decompensated heart failure; • INTERMACS frequent flyer profile; • chronic renal failure (estimated glomerular filtration rate <50 ml/min per 1.73 m2: KDOQI classification stage 3 chronic kidney disease); • no obvious contraindications to peritoneal UF. PUF treatment modes are derived from the treatment regimens proposed by various authors to obtain systemic UF in patients with severe decompensated heart failure, using manual and automated incremental peritoneal dialysis involving various glucose concentrations in addition to the single icodextrin exchange. These guidelines also identify a minimum set of tests and procedures for the follow-up phase, to be supplemented, according to the center's resources and policy, with other tests that are less routine or more complex also from a logistic/organizational standpoint, emphasizing the need for the patient's clinical and treatment program to involve both the nephrologist and the cardiologist. The pathophysiological aspects of a deterioration in kidney function in patients with decompensated heart failure are also considered, and the results of PUF in patients with decompensated heart failure reported in the various case series are reviewed.