Outcomes of transperineal and transrectal ultrasound-guided prostate biopsy.

OBJECTIVE: To compare the clinical outcomes and pathological findings of transperineal ultrasound-guided prostate biopsy (TPUSPB) and transrectal ultrasound-guided prostate biopsy (TRUSPB) in a secondary referral hospital. METHODS: This was a retrospective study of 100 TPUSPBs and 100 TRUSPBs performed in our centre. Pre-biopsy patient parameters (eg, patient age, clinical staging, serum prostate-specific antigen [PSA] level, prostate size, and PSA density), as well as pathological results and 30-day complication and readmission rates, were retrieved from the patients' medical records and compared between the two groups. RESULTS: One hundred TPUSPBs performed from January 2018 to May 2018 and 100 TRUSPBs performed from January 2016 to April 2016 were included for analysis. Mean age did not significantly differ between the groups. The TPUSPB group had a higher mean PSA level, smaller prostate size, and higher PSA density, compared with the TRUSPB group. The overall prostate cancer detection rate was similar between the TPUSPB and TRUSPB groups (35% vs 25%, P=0.123). There were no significant differences between the groups in prostate cancer detection rates after stratification according to PSA density and clinical staging. With respect to complications, no patients developed fever in the TPUSPB group, while 4% of patients in the TRUSPB group had fever and required at least 1-week admission for intravenous antibiotic administration. CONCLUSION: For prostate biopsy, TPUSPB is safer, with no infection complications, and has similar prostate cancer detection rate compared with TRUSPB.

Outcome Evaluation of a Short-Term Hospitalization and Community Support Program for People Who Abuse Ketamine.

Ketamine is a popular recreational drug among young people in Hong Kong. Long-term abuse of ketamine can lead to acute urological and medical issues, which often require immediate care at emergency rooms. Many patients require short-term hospitalization for medical management. This opens a brief time window, within which mental health professionals could engage young people who abuses ketamine in psychosocial, functional, and lifestyle interventions. The Crisis Accommodation Program (CAP) is a short-term hospitalization and community support program that addresses the health care needs of young people who abuse ketamine. During short-term hospitalization, the patient participates in a range of cognitive and psychosocial assessments, motivational interviewing, emotions management, and lifestyle re-design interventions. Upon discharge, social work professionals of non-government agencies continue to work with the patients on their action plans in the community. This evaluation study uses a quasi-experimental non-equivalent group design, in which the outcomes of the treatment group (n = 84) are compared with a comparison group (n = 34) who have a history of ketamine abuse but who have not joined the treatment program. The results confirm that the treatment group showed significant increases in motivation for treatment, reduction in drug use, improvement in cognitive screening tests, healthy lifestyle scores, and self-efficacy in avoidance of drugs over 13 weeks. When compared with the comparison group, the treatment group had significant decreases in anxiety and treatment needs and had moved from pre-contemplation to the contemplation or preparation stage. However, there were no significant changes in outcome measures covering lifestyle or self-efficacy in drug avoidance. Overall, the CAP is effective in reducing drug use, anxiety, and helping patients to move from pre-contemplation to the contemplation or preparation stage of change. The study results suggest that health care professionals can successfully engage young people who abuse ketamine to participate in a package of psychosocial interventions, motivational interviewing, and lifestyle re-design during their hospital stay for management of urological problems. The CAP also highlights the importance of collaboration between hospitals and community social services in the management of addiction.

Photoselective vaporisation prostatectomy using a GreenLight High Performance System for patients with bleeding tendency.

OBJECTIVES: To report the results of a modified vaporisation incision technique using a GreenLight High Performance System in the treatment of benign prostatic disease in men receiving anticoagulants. DESIGN: Case series. SETTING: Regional hospital, Hong Kong. PATIENTS: From January 2007 to April 2010, 48 patients with a bleeding tendency or on oral anticoagulants who underwent photoselective vaporisation prostatectomy with a GreenLight High Performance System in the North District Hospital were studied. Data collected prospectively were analysed to determine perioperative and postoperative outcomes, including uroflowmetry parameters, serum prostate-specific antigen level, prostate volume, and complications at 1, 3, 6, and 12 months post-surgery. RESULTS: The patients' mean age was 76 (standard deviation, 7; range 62-94) years. The mean follow-up period was 13 (standard deviation, 9) months. Thirty-six (75%) patients had urinary retention prior to surgery. Bleeding tendencies were due to receipt of aspirin (n=36), two antiplatelet agents (n=6), warfarin (n=4) and clopidogrel (n=1), and to thrombocytopaenia (n=1). Preoperative transrectal ultrasonography showed a mean prostate size of 58 (standard deviation, 30; range, 18-154) mL. Of the patients, 81% were discharged without a catheter and their mean hospital stay was 3 days. Five patients were readmitted for secondary haemorrhage, two had a drop of more than 10 g/L in their haemoglobin level, but only one received a blood transfusion. Mean uroflowmetry parameters, namely, peak flow rate and residual volume, were 8.7 mL/s and 199 mL preoperatively and 14.7 mL/s and 50 mL 1 year after the operation. CONCLUSION: With an ageing population in which patients with various co-morbidities receive anticoagulant/antiplatelet therapy, photoselective vaporisation prostatectomy using a GreenLight High Performance System is a safe treatment option.

Increased α-synuclein phosphorylation and nitration in the aging primate substantia nigra.

Post-translational modifications of α-synuclein occur in the brain of patients affected by Parkinson's disease and other α-synucleinopathies, as indicated by the accumulation of Lewy inclusions containing phosphorylated (at serine 129) and nitrated α-synuclein. Here we found that phospho-Ser 129 and nitrated α-synuclein are also formed within dopaminergic neurons of the monkey substantia nigra as a result of normal aging. Dopaminergic cell bodies immunoreactive for phospho-Ser 129 and nitrated α-synuclein were rarely seen in adult mature animals but became significantly more frequent in the substantia nigra of old primates. Dual labeling with antibodies against phospho-Ser 129 and nitrated α-synuclein revealed only limited colocalization and mostly stained distinct sub-populations of dopaminergic neurons. Age-related elevations of modified protein paralleled an increase in the number of neurons immunoreactive for unmodified α-synuclein, supporting a relationship between higher levels of normal protein and enhanced phosphorylation/nitration. Other mechanisms were also identified that likely contribute to α-synuclein modifications. In particular, increased expression of Polo-like kinase 2 within neurons of older animals could contribute to phospho-Ser 129 α-synuclein production. Data also indicate that a pro-oxidant environment characterizes older neurons and favors α-synuclein nitration. Aging is an unequivocal risk factor for human α-synucleinopathies. These findings are consistent with a mechanistic link between aging, α-synuclein abnormalities and enhanced vulnerability to neurodegenerative processes.

Lower urinary tract changes in young adults using ketamine.

PURPOSE: We identified the profile of lower urinary tract changes in ketamine users in the community. In addition, we identified the relative risks of dose, frequency of ingestion and duration of ketamine use for changes in lower urinary tract function. MATERIALS AND METHODS: A mobile medical assessment service was established at specific youth centers, and subjects who were known to social workers and who had a history of ketamine use were invited to participate in health screening. Lower urinary tract function was evaluated using the Pelvic Pain, Urgency and Frequency questionnaire, and uroflowmetry and ultrasonography. RESULTS: Use of ketamine more than 3 times weekly was significantly associated with lower voided volumes. Pelvic Pain, Urgency and Frequency questionnaire scores were significantly higher for ketamine use for more than 24 months compared to use for short durations (7.82 vs 6.00). The scores on the symptom and bother subscales of the Pelvic Pain, Urgency and Frequency questionnaire decreased progressively with increased duration of abstinence. For individuals after 1 year of abstinence the Pelvic Pain, Urgency and Frequency questionnaire scores were significantly lower and voided volumes were higher than those for active users. CONCLUSIONS: Ketamine users with at least a 2-year habit of 3 or more hits per week have altered bladder function that can be recognized and that causes bother. These early functional changes have the potential to normalize after 1 year of ketamine abstinence. This study provides a basis for the development of health promotion material that can be used in the community by welfare workers seeking to encourage drug cessation.

Derivation of a prognostic score for identifying critically ill patients in an emergency department resuscitation room.

INTRODUCTION: Several prognostic scores exist for critically ill patients, including APACHE II, Revised Trauma Score (RTS), Rapid Emergency Medicine Score (REMS) and Modified Early Warning Score (MEWS). However, there is no widely used score specifically designed to predict the likelihood of early intensive care unit (ICU) admission or death in undifferentiated emergency department (ED) resuscitation room patients. We aimed to derive such a score and compare it with other similar scores. METHODS: This was a single centre study of consecutive adult resuscitation room patients over one month. Physiological and blood test variables were compared according to the composite primary outcome: admission to ICU or death within 7 days of attendance. Multivariate logistic regression was used to derive a prediction score which was compared with other scores using ROC (receiver operating characteristic) analysis. RESULTS: 330 patients were included in the study, of whom 77 were admitted to ICU or died within 7 days. A prediction score was derived using the following parameters: systolic blood pressure; Glasgow coma score; blood glucose; bicarbonate; white cell count; and a history of metastates. This score significantly out-performed APACHE II, RTS, REMS and MEWS with an area under the ROC curve of 0.909 (95% CI 0.872-0.938). CONCLUSION: The Prince of Wales Emergency Department Score (PEDS) is a new prognostic score to predict the likelihood of early ICU admission or death in undifferentiated resuscitation room patients. Further studies are needed to validate and refine this potentially useful tool.

Refractory thrombotic thrombocytopenic purpura and membranoproliferative glomerulonephritis successfully treated with rituximab: a case associated with hepatitis C virus infection.

Plasmapheresis remains the main treatment modality for patients with thrombotic thrombocytopenic purpura. We report a patient who had simultaneous onset of membranoproliferative glomerulonephritis and thrombotic thrombocytopenic purpura. She did not improve after 48 plasmapheresis sessions. A 6-week course of weekly intravenous doses of rituximab was then given. This achieved complete remission of her nephrotic syndrome and improvement in her renal function, so plasmapheresis was ceased. She had a low ADAMTS13 antigen level and a positive ADAMTS13 antibody, both of which reverted to normal after treatment with rituximab. This coincided with a rise in her hepatitis C virus RNA and liver transaminases. Liver biopsies did not reveal active fibrosis. Her hepatitis C virus RNA titre dropped afterwards, and she had no relapses of her thrombotic thrombocytopenic purpura and nephrotic syndrome, for more than 2 years after remission. The simultaneous onset and successful outcomes of both the membranoproliferative glomerulonephritis and thrombotic thrombocytopenic purpura illustrate the usefulness of rituximab. We discuss its use and risks, in the context of chronic hepatitis C infection.

The prevalence of cardiovascular risk factors in male patients who have lower urinary tract symptoms.

OBJECTIVES: To assess the prevalence of cardiovascular risk factors in men presenting with lower urinary tract symptoms, and their possible correlation with the severity of such symptoms. DESIGN: Retrospective cohort study. SETTING: Specialty clinic, Hong Kong. PATIENTS: A total of 617 men presenting with lower urinary tract symptoms between April 2005 and October 2006. MAIN OUTCOME MEASURES: Presence of cardiovascular risk factors inferred from the prior and current medical and social history as well as physical examination and investigative findings, among patients with International Prostatic Symptom Scores of different severity. RESULTS: Of 617 patients, 268 (43%) had known hypertension and 318 (52%) had a history of smoking. According to the World Health Organization criteria for Asian populations, 396 (64%) patients were considered to be overweight (body mass index > or =23 kg/m(2)). A total of 178 (29%) patients were either known to have or were diagnosed to have dysglycaemia during workup. For dyslipidaemia and hyperuricaemia, the corresponding figures were 331 (54%) and 191 (31%). In total, 264 (43%) patients were newly diagnosed as having dysglycaemia, dyslipidaemia, or hyperuricaemia. Logistic regression indicated that only hyperuricaemia and a smoking history were significant predictors of moderate-to-severe lower urinary tract symptoms (International Prostatic Symptom Score > or =8), with respective adjusted odds ratios of 2.20 (95% confidence interval, 1.12-4.31; P=0.022) and 2.11 (1.24-3.57, P=0.006). Patients with moderate-to-severe International Prostatic Symptom Scores had a statistically higher chance of having at least one cardiovascular risk factor during assessment (P=0.001). CONCLUSIONS: Cardiovascular risk factors were prevalent in male patients who had lower urinary tract symptoms; a large portion of these cardiovascular risk factors were not recognised until their urological consultations. Patients with moderate-to-severe lower urinary tract symptoms (International Prostatic Symptom Score > or =8) had statistically higher chances of having more cardiovascular risk factors.

Prevalence of subclinical infection and transmission of severe acute respiratory syndrome (SARS) in a residential care home for the elderly.

OBJECTIVE: To ascertain the prevalence of subclinical severe acute respiratory syndrome-coronavirus (SARS-CoV) infection and study the transmission of SARS-CoV in a local outbreak at a residential care home for the elderly. DESIGN: Cross-sectional study. SETTING: A residential care home for the elderly in Hong Kong with a local outbreak of SARS. PARTICIPANTS: Residents and staff in the residential care home who had contact with three patients with SARS (residents A and B, and staff C). MAIN OUTCOME MEASURES: Blood samples were tested for total antibodies to SARS-CoV by immunofluorescence antibody test. The transmission of SARS was elucidated based on information from standardised questionnaires, and records of investigation and surveillance by the Department of Health. RESULTS: Among the 90 eligible residents, three died, one moved out, and 19 refused to participate. Of the 32 eligible staff, six refused to participate. None of the remaining 93 participants tested positive for antibody to SARS-CoV. Based on the chronological order, resident A might have transmitted infection to resident B and staff C. Sitting close to the bathroom doorway while resident A took a shower was the only contact of resident B with resident A. The only opportunity for staff C to have contact with body fluids/excreta of resident A was in the handling of rubbish from the resident's room. CONCLUSION: Subclinical SARS-CoV infection was rare in a residential care home for the elderly with an outbreak of SARS. Nonetheless the close working and living conditions for staff and residents in such a home may facilitate transmission of SARS despite vigilant precautionary measures.

Factors associated with poorly-controlled hypertension in continuous ambulatory peritoneal dialysis patients.

INTRODUCTION: Hypertension is highly prevalent among continuous ambulatory peritoneal dialysis (CAPD) patients and is a major risk factor for cardiovascular complications. This study examines the risk factors associated with poorly-controlled hypertension in CAPD. METHODS: We performed a cross-sectional study of 66 stable adult CAPD patients to evaluate their hypertension control over a period of three to four months and their associations with other clinical and laboratory parameters. RESULTS: The mean age of the patients was 56.7 (plus or minus 1.27) years. Their mean systolic and diastolic blood pressure were 139 (plus or minus 2.59) mmHg and 77 (plus or minus 1.35) mmHg respectively; 71 percent of them were on antihypertensive drugs. Thirty (45.5 percent) patients had high blood pressure greater than 140/90mmHg. Compared with patients with normal blood pressure, patients with high blood pressure received significantly more antihypertensive drugs (p-value equals 0.034) and were more likely to be clinically overloaded (p-value less than 0.001). Multivariate analysis showed that systolic blood pressure was predicted by volume expansion (p-value less than 0.001) while diastolic blood pressure was negatively predicted by age (p-value equals to 0.004). In addition, volume overload was predicted positively by dialysate/plasma creatinine (p-value equals 0.011) and negatively by serum albumin (p-value less than 0.001). CONCLUSION: Clinically-apparent volume overload was associated with poor systolic blood pressure control despite aggressive antihypertensive drug therapy. This finding underlines the importance of fluid control and could provide an explanation of the poor outcome observed in patients with high peritoneal transport.

The effects of acute sleep deprivation on performance of medical residents in a regional hospital: prospective study.

OBJECTIVE: To evaluate the effects of acute sleep deprivation on the level of perceived occupational stress and cognitive functioning in a group of medical residents. DESIGN: Prospective study. SETTING: Regional hospital, Hong Kong. PARTICIPANTS: Twenty-one residents who had regular in-hospital on-call duties. MAIN OUTCOME MEASURES: From January to April 2002, participants were asked to complete the Raven Advanced Progressive Matrices (sets I and II) and Occupational Stress Inventory-Revised tests at the beginning of an on-call day. They then repeated the tests towards the end of their on-call duties on their next on-call day, at a mean (standard deviation) interval of 8.9 (2.3) days. Occupational Stress Inventory-Revised test scores were transformed into T-scores to provide information about an individual's scores relative to the scores of participants in a normative sample. RESULTS: The group slept for a mean (standard deviation) of 2.9 (1.0) hours during 29.3 (3.8) hours of on-call duties. Before the on-call duties, participants' mean T-scores for the Occupational Stress Inventory-Revised test ranged from 50.6 to 54.5 for the Occupational Role Questionnaire, 52.0 to 57.0 for the Personal Strain Questionnaire, and 37.3 to 52.3 for the Personal Resources Questionnaire. After on-call duties, apart from a slight increase in Role Insufficiency T-scores (50.6 [5.9] versus 52.1 [6.0]; P=0.044), there was no significant change in all other scales of the Occupational Stress Inventory-Revised test. The scores of the Raven Advanced Progressive Matrices test remained stable after the on-call duties (11.3 [1.2] versus 11.5 [0.8], P=0.129 for set I; 29.9 [5.5] versus 30.2 [6.3], P=0.2 for set II). CONCLUSION: Acute sleep deprivation among medical residents was not associated with any significant changes in both cognitive functioning and level of stress perceived.

A retrospective study on efficacy of proton-pump inhibitor-based triple therapy for eradication of Helicobacter pylori in patients with chronic renal failure.

OBJECTIVE: The efficacy of short-course triple eradication therapy has been documented in patients with Helicobacter pylori infection and normal renal function. We have evaluated a one-week proton-pump inhibitor-based triple therapy for Helicobacter pylori eradication in a retrospective review of patients with chronic renal failure. METHODS: We studied 25 patients (mean age 65.1 +/- 2.4 years) with creatinine clearance <30 ml/min/1.73 m2 or serum creatinine level >200 micromol/L (13 on dialysis), who had Helicobacter pylori infection, documented by histological examination or rapid urease test, together with either peptic ulcer disease or severe gastritis. The combination of Omeprazole 20 mg BID or Lansoprazole 30 mg BID, amoxicillin 1 gm BID and clarithromycin 500 mg BID was given for one week, in addition to therapy for peptic ulcers. All patients were re-endoscoped four weeks later. RESULTS: All but one patient (96%) had successful eradication. On repeat endoscopy, all 13 patients with peptic ulcers had healed ulcers. For the 12 gastritis patients, three became normal and nine had persistent gastritis. For patients not on dialysis, the serum creatinine level and creatinine clearance remained stable at two weeks after treatment (303 +/- 37 vs. 330 +/- 36 micromol/l, p=ns; 23.6 +/- 3.4 vs. 26.0 +/- 3.9 ml/min/1.73 m2, p=ns, respectively). CONCLUSION: The short course triple therapy was highly efficacious for Helicobacter pylori eradication in patients with chronic renal failure, with no adverse effect on renal function.

Two liters of polyethylene glycol-electrolyte lavage solution versus sodium phosphate as bowel cleansing regimen for colonoscopy: a prospective randomized controlled trial.

BACKGROUND AND STUDY AIMS: As a bowel cleansing agent for colonoscopy, sodium phosphate (NaP) has been reported to have equal effectiveness and better patient tolerance in comparison with 4 l polyethylene glycol-electrolyte lavage (PEG-EL) solution. Poor patient tolerance is frequently associated with a large amount of fluid consumed, and better patient tolerance might therefore be expected if the volume of PEG-EL solution could be reduced. This study aimed to compare 2 l PEG-EL solution with NaP in relation to patients' tolerance and its effectiveness as a bowel cleansing agent. PATIENTS AND METHODS: Two hundred consecutive patients admitted to the day-procedure ward for elective colonoscopy were prospectively randomized to receive either a 2-l PEG-EL solution or a 90-ml oral NaP regimen. Patients with a history of congestive heart failure, impaired renal function (creatinine > 1.5 mg/dl), or previous colectomy were excluded from the study. The patients completed a questionnaire to assess their tolerance of bowel preparation before the colonoscopy. Endoscopists, who were blinded to the type of regimen that had been used, scored the adequacy of bowel preparation from the rectum to cecum using a defined endoscopic score. RESULTS: Two hundred patients were included in this randomized trial. Nine patients were excluded, due to either an incomplete questionnaire (two in the PEG-EL group, one in the NaP group) or inability to complete the bowel preparation regimen (four in the PEG-EL group and two in the NaP group). The demographic data were comparable in the two groups. There were no differences between the two groups with regard to willingness to repeat the regimen, ease of consumption, acceptability of the bowel preparation regimen, or the endoscopists' satisfaction with the quality of bowel preparation. The NaP group had a better mean endoscopic score at the cecum compared with the PEG-EL group (1.47 +/- 1.15 vs. 1.05 +/- 0.76; P = 0.007). CONCLUSIONS: The effectiveness and patient tolerance of the 2-l PEG-EL solution is comparable with that of oral NaP. The 2-l PEG-EL solution is therefore an effective alternative as a bowel-cleansing agent for colonoscopy.

Primary hyperoxaluria: a rare but important cause of nephrolithiasis.

We report on a middle-aged man with end-stage renal failure apparently secondary to recurrent renal stones. He developed systemic oxalosis soon after commencing dialysis. The diagnosis of primary hyperoxaluria type 1 was supported by the finding of high dialysate glycolate excretion. The patient subsequently received an isolated cadaveric renal transplant, but the outcome was a rapid recurrence of oxalosis and early graft failure. Although isolated liver or renal transplantation in addition to various adjuvant measures may be considered in the early stage, combined liver-kidney transplantation remains the only definitive therapy for a patient with end-stage renal failure and systemic oxalosis due to hyperoxaluria type 1. This case illustrates the possible late presentation of primary hyperoxaluria type 1 and the poor outcome with isolated renal transplantation after the development of systemic oxalosis. One should thus have a high index of suspicion in patients with recurrent renal stones of this rare, but nevertheless important, entity.

Prospective study on renal outcome of IgA nephropathy superimposed on diabetic glomerulosclerosis in type 2 diabetic patients.

BACKGROUND AND METHODS: In order to examine the clinical outcome of IgA nephropathy (IgAN) superimposed on diabetic glomerulosclerosis in type 2 patients we studied 36 Chinese patients (26 men, 10 women), who were recruited for renal biopsy when they had proteinuria of more than 1 g/day. Twenty-seven had isolated diabetic glomerulosclerosis and nine had IgAN superimposed on diabetic glomerulosclerosis (combined). Renal function was assessed by serial serum creatinine, 24-h urine protein and creatinine measurements. Patient survival rate, incidence of end-stage renal disease (ESRD), blood pressure, and glycaemic control status were determined. RESULTS: The age at the time of renal biopsy was younger for the combined group when compared with the diabetic glomerulosclerosis group (44+/-3.6 vs 58+/-2.1 years, P=0.006). The duration of diabetes was, however, similar for the two groups (8.0+/-2.3 vs 6.7+/-1.2 years, P=NS). After a mean follow-up of 31.6+/-15.3 months, 15 patients (one in the combined group and 14 in the diabetic glomerulosclerosis group) developed ESRD. Nine patients (all in the diabetic glomerulosclerosis group) died during follow-up. With similar glycaemic and blood pressure control, the two groups had comparable rate of decline of creatinine clearance (CrCl) (-0.73+/-0.26 vs -0.73+/- 0.18 ml/min/1.73 m(2)/month, P=NS), final serum creatinine (363+/-134 vs 426+/-52 micromol/l, P=NS) and proteinuria levels (4.3+/-0.9 vs 4.4+/-0.6 g/day, P=NS), as well as CrCl (44.1+/-19.0 vs 33.4+/-6.9 ml/min/ 1.73 m(2), P=NS). CONCLUSION: It is concluded that the superimposed IgAN does not significantly alter the medium-term clinical outcome of patients with diabetic glomerulosclerosis.

Randomized prospective study of the effect of increased dialytic dose on nutritional and clinical outcome in continuous ambulatory peritoneal dialysis patients.

Cohort studies have shown that greater urea (Kt/V) and creatinine clearances (CCr) were associated with better survival in patients on continuous ambulatory peritoneal dialysis (CAPD). The possibility of improved patient outcome with increased dialytic dose remains unknown. We prospectively studied over 1 year the effects of an extra 2-L bag on the outcome of 82 patients undergoing three daily 2-L exchanges for at least 12 months. At 1 year, 36 patients were undergoing 6-L exchanges, whereas 30 patients underwent 8-L exchanges. The increased dialytic dose resulted in increased total weekly Kt/V (TKt/V; 1.82 to 2.02), whereas total weekly CCr (TCCr) was maintained (63.2 to 61.9 L/1.73 m(2)). Control patients had reduced solute clearances (TKt/V, 1.87 to 1.67; TCCr, 64.8 to 54.6 L/1.73 m(2)). The fourth bag exchange resulted in a significant increase in net ultrafiltration (0.83 to 1.51 L/d), whereas the control group also had greater ultrafiltration (0.68 to 1.01 L/d) after 1 year. Although the normalized protein equivalent of nitrogen appearance (nPNA) was stable in the controls, the patients using 8-L exchanges achieved a greater nPNA (1.10 to 1.24 g/kg/d). There was no associated change in serum albumin levels (3.79 to 3.48 g/dL). The hospitalization rate increased in the controls (0.9 to 1.8 admissions/12 mon), whereas it was unchanged in the patients using 8-L exchanges. In conclusion, a 33% increase in dialytic prescription led to increased peritoneal and total clearances. Despite achieving increased nPNA (13%), the serum albumin level was unchanged. However, the increased hospitalization rate observed in the controls was avoided in the group using 8-L exchanges.