Relationship between Kt/V urea-based dialysis adequacy and nutritional status and their effect on the components of the quality of life in incident peritoneal dialysis patients.

BACKGROUND: It is well known that the quality of life of patients with chronic kidney disease can be improved by dialysis. While previous studies have used retrospective designs and adhered to a standard target prescribed by clinical guidelines, our study prospectively investigates the association between the adequacy of peritoneal dialysis (PD) and measures of nutritional status on quality-of-life domains in a cohort of incident PD patients. METHODS: It was a prospective 6-month observational study. Eighty incident PD participants who were treated in a hospital-based PD center were enrolled. The period of enrollment was January 2009-June 2010; follow-up continued until December 2010. PD adequacy indices, including Kt/V urea, weekly Ccr (WCcr), measures of nutritional status (albumin, BMI), and nPCR were measured at 1 month and 6 months after PD initiation. SF-36 health survey questionnaires were used to measure the quality of life. The outcomes were used to measure the changes in the domains of the SF-36 after 6 months of PD therapy. RESULTS: Seventy-seven incident patients who underwent PD for 6 months were included in the study. The mean age was 47.3 years, and the male-to-female ratio was 38:39. A peritoneal Kt/V urea value of 1.2, which was also the baseline cutoff value, was found to have the highest influence on SF-36 domains. Patients with baseline peritoneal Kt/V urea value of <1.2 showed improvement in the physical functioning and role limitation of physical functioning components after 6 months of PD. In contrast, patients with baseline peritoneal Kt/V urea values of ≥1.2 showed remarkable improvement in the general health, physical functioning, role limitation caused by physical problems, and bodily pain components. However, the trend of improvement decreased in patients with baseline nPCR of <1.2. Baseline renal WCcr did not influence the improvement in the SF-36 domains. LIMITATIONS: A small cohort and a short observation period. CONCLUSIONS: The baseline level of peritoneal Kt/V urea affected the components of the quality of life after PD initiation. In contrast, a lower baseline nPCR level was associated with deterioration in the quality of life after PD therapy.

Albuminuria, proteinuria, and urinary albumin to protein ratio in chronic kidney disease.

BACKGROUND: Both albuminuria and proteinuria are important disease markers of chronic kidney disease (CKD). Their relationship and the ratio between urinary albumin and protein in patients with CKD have not been investigated. Whether clinical features can affect these measurements is not clear. METHODS: We conducted a cross-sectional study in 602 CKD patients. Demographic data, including age, gender, and co-morbidity such as diabetes, hypertension, hyperuricemia, and hyperlipidemia, were reviewed and recorded. Their urinary albumin, total protein, and creatinine were determined and urinary albumin to creatinine ratio (UACR), total protein to creatinine ratio (UPCR), and albumin to total protein ratio (UAPR) were calculated. Their estimated glomerular filtration rate (eGFR) was calculated according to serum creatinine. The correlation between UACR and UPCR was thus analyzed. We also investigated factors associated with these urinary measurements. RESULTS: UACR and UPCR increased progressively as renal function deteriorated, while UAPR increased to a plateau in CKD stage 4. There was direct relationship between UACR and UPCR. UAPR rose exponentially with the increase of both UACR and UPCR when UACR <500 mg/g or UPCR <1,000 mg/g. Multivariate regression analysis revealed diabetes and hyperuricemia were associated with increased UACR and UPCR, while both urinary parameters were inversely related to male gender and eGFR. Diabetes and hyperuricemia were associated with increased UAPR and UAPR was negatively correlated with age and eGFR. CONCLUSION: There was a significant association between UACR and UPCR in patients with CKD. Characteristics of patients, renal function, and co-morbidities all affected UACR, UPCR, and UAPR.

Better sleep quality and less daytime symptoms in patients on evening hemodialysis: a questionnaire-based study.

The aims of this study were to investigate the prevalence of sleep disorders in patients with end-stage renal disease (ESRD), and to assess the effect of dialysis schedule on sleep quality and the presence of daytime symptoms. We prospectively selected 150 long-term hemodialysis (HD) patients in three groups (morning, afternoon, and evening dialysis) and gave them a sleep questionnaire, the Epworth sleepiness scale and the Pittsburgh sleep quality index. Snoring was the most common complaint (56%), followed by insomnia (38%) and restless legs syndrome (22.7%). The evening dialysis group experienced more sleep time in bed (P = 0.02), required less hypnotic medication (P = 0.049), had fewer daytime symptoms (P < 0.01), and experienced less daytime sleepiness (P = 0.034). Our study confirms the high prevalence of sleep disorders in ESRD patients, and indicates a beneficial effect of evening HD on sleep quality and reduction of daytime symptoms.

Hypercalcemia in the emergency department.

BACKGROUND: Severe hypercalcemia can be life-threatening. However, its incidence and the underlying causes in the emergency department (ED) have not been determined. In the present study, we investigated these issues and the impacts on renal function and patients' survival. METHODS: We performed a retrospective study to analyze the patients with hypercalcemia in the ED for 1 year. Serum total calcium level greater than 10.3 mg/dL was defined as hypercalcemia. RESULTS: During the study period, 321 of 4293 patients (7.5%) were found to have hypercalcemia (serum calcium 11.7 +/- 1.6 mg/dL). Most of them had mild hypercalcemia (calcium level < 12.0 g/dL, 70.7%). Malignancy (36.4%) and uremia (32.4%) were the most common underlying causes. Normal renal function was observed in only 75 (23.4%) of all patients with hypercalcemia. The total mortality rate was 23.1%, and death was associated with male gender, higher calcium level, lower hemoglobin, and malignancy (all P < 0.05). Logistic analysis found that serum calcium and hemoglobin levels were independent risk factors for mortality. CONCLUSIONS: Severe hypercalcemia is frequently and life-threatening in the ED. Therefore routine determination of serum calcium level is recommended, and immediate therapy should be initiated to treat the patients at high risk.

Ultrasound localization of the femoral vein facilitates successful cannulation for hemodialysis.

BACKGROUND: Real-time ultrasound-guided techniques allow for improved cannulation of the internal jugular vein and femoral vein for hemodialysis; however, these techniques require extra sterilization procedures, specialized probes, or needle guides. A simpler ultrasound vessel localization method was performed to investigate whether this alternative approach would aid in the cannulation of the femoral vein for patients in whom temporary angioaccess was required for hemodialysis. METHODS: Patients requiring temporary femoral vein catheters for hemodialysis were divided into 2 groups on alternating days of the week during a 6-month period. One group underwent ultrasound localization of the femoral vein before cannulation and the second group received conventional landmark localization. Data regarding the strength of the femoral arterial pulse, number of attempts, failures, and complications were recorded. RESULTS: Ultrasound localization resulted in significantly improved first-attempt success rates, reduced attempts, and reduced failure and complication rates overall (p < 0.001, p < 0.001, p = 0.002 and p = 0.004 respectively) as well as in the group of patients with a clearly discernible arterial pulse (p < 0.001, p = 0.001, p = 0.004 and p = 0.011 respectively). The same trend was observed among patients with faintly palpable or non-palpable femoral arterial pulses, although the differences were not statistically significant. CONCLUSION: Cannulation of the femoral vein for hemodialysis should be performed with the aid of ultrasound. If real-time ultrasound-guided cannulation is not available, the vessel localization method is a good alternative, given its known limitations and the fact that it is simpler. It remains to be determined whether 1 - dimensional localization or localization including vessel depth information can improve outcomes in patients with faintly palpable or non-palpable femoral arterial pulses.

Sex differences in kidney size and clinical features of patients with uremia.

BACKGROUND: Ultrasonographic evaluation of the kidney size is a useful method for assessment of the progression and, in some cases, the type of nephropathy. Ultrasonography (USG) also plays an important role in the evaluation of both acute and chronic renal failure. OBJECTIVE: To investigate the ultrasonographic appearance of the kidneys in patients with uremia, underlying renal diseases and clinical characteristics, including biological sex, were studied. METHODS: This was a retrospective study of data from consecutive adult patients with uremia starting a dialysis program between January 2005 and December 2006 at the nephrology department of a university hospital in Taiwan. Kidney size was determined by USG; demographic and clinical data were obtained prior to initiation of dialysis. RESULTS: Of the patients (167 men, 151 women) included in the analysis, diabetes mellitus (DM) was the leading cause of uremia (127/318; 39.9%). The distribution of DM was similar between male and female patients. In addition to levels of blood urea nitrogen and hemoglobin, body mass index was similar between male and female patients (mean [SD], 22.9 [3.1] vs 22.1 [3.4] kg/m(2), respectively). Female patients had significantly lower serum creatinine levels (P < 0.05) and higher estimated glomerular filtration rates (P < 0.01) than did male patients when they initiated chronic dialysis therapy. Among those with DM, male patients were younger and had larger kidney size on initiation of dialysis therapy than did female patients (age, 59.9 [9.4] vs 64.6 [11.9] years; right renal length, 10.3 [1.4] vs 9.5 [1.5] cm; left renal length, 10.4 [1.5] vs 9.5 [1.4] cm; all, P < 0.05). These sex differences in age and kidney size at the start of dialysis were not observed in patients who did not have DM. Patients with DM had significantly larger kidney size than those without DM (P < 0.05). CONCLUSIONS: The kidney size of these uremic patients varied considerably, depending on sex and the underlying disease. Male patients with DM at the terminal stage of renal failure had larger kidney size and were younger at the start of dialysis therapy than female patients with DM. In uremic patients without DM, no such discrepancy was observed, and both male and female patients started dialysis therapy at a comparable age and kidney size.

A longitudinal change of peritoneal equilibration test results in peritoneal dialysis patients aged 60 years and above: a 4-year observation study in comparison with a younger group.

BACKGROUND: The number of elderly people with end-stage renal disease has grown in developed countries and medical teams now face the choice of dialysis therapy in elderly patients. In the present study, we retrospectively analyzed two peritoneal dialysis (PD) patients, of different ages, who were treated at the same unit by the same PD team of doctors and nurses. Our purpose was to study peritoneal membrane changes in elderly and younger PD patients. METHODS: 108 patients above 60 years of age or younger at the start of dialysis, were separated into two cohorts. Diabetic patients were excluded. Peritoneal equilibration test (PET) results taken over 4 continuous years were compared between the two groups. RESULTS: No significant differences were seen between the two groups in peritoneal transport (D/P Cr, D/D0 glucose) during the 4-year observation. Total Kt/V and renal creatinine clearance (Ccr) values in the 4-year period were not significantly different between the two groups. Renal Ccr values showed a longitudinal decline in the two groups but the values of total Kt/V revealed a consistency over the 4-year period. CONCLUSION: Elderly PD patients demonstrated a similar peritoneal permeability to younger PD patients based on a 4-year PET.

Longitudinal change in peritoneal membrane function with continuous ambulatory peritoneal dialysis (CAPD) after peritonitis episodes.

BACKGROUND: To assess changes in the peritoneal membrane after peritonitis episodes in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). METHODS: From 1989 to 2002, CAPD patients who had peritonitis episodes were enrolled. We used the peritoneal equilibration test (PET) and measured plasma creatinine (Cr) levels at 2 hours, and dialysate Cr and glucose levels at 0, 2, and 4 hours. In addition, the dialysate-to-plasma ratio of Cr (D/PCr) at 0, 2, and 4 hours, the ratio of glucose levels in the dialysate effluent and infused dialysate ((D/D0)G), the drained ultrafiltration (UF) volume at 4 hours, and the mass transfer area coefficient of Cr (MTAC) normalized for the body surface area were also calculated. D/PCr, (D/D0)G, UF volume, and MTAC were measured at the baseline and after 2 years, and the results were analyzed and compared. RESULTS: Totally 27 patients were enrolled in the peritonitis group, including 17 males and 10 females. They had received CAPD for 71.23 +/- 28.13 months. Forty-nine peritonitis episodes were noted during the study period. Twenty-four patients were enrolled as controls, including 9 males and 15 females. They had undergone CAPD for 55.83 +/- 25.94 months. The baseline and 2-year levels of D/PCr (0.66 +/- 0.11 vs. 0.62 +/- 0.10, p<0.05), (D/D0)G (0.37 +/- 8.45 vs. 0.43 +/- 7.71, p<0.05), and MTAC (9.36 +/- 3.53 vs. 8.08 +/- 3.41, p<0.05) showed significant changes, but UF volume (253.70 +/- 224.43 vs. 311.54 +/- 186.71 ml, p>0.05) showed no significant change. In the control group, there were no significant changes in D/PCr, (D/D0)G, MTAC, or UF volume. CONCLUSION: Peritonitis episodes affect the peritoneal membrane solute transport function in CAPD patients.