Utility of Remote Monitoring in Patients on Automated Peritoneal Dialysis

ABSTRACT Home hemodialysis (HD) and automated peritoneal dialysis (APD) have advantages over HD in hospitals or HD centers. Home therapies are generally less expensive and give patients greater mobility and freedom for work, school, family, and recreational activities. Technological advances have made it possible to complement APD with devices for remote monitoring (RM) of the patient. With them, objective information generated in the APD device is collected and sent to repositories "in the cloud" for analysis or at the time decided by the health team. With APD+RM, it is possible to monitor therapeutic compliance, effective dialysis time, ultrafiltration volumes, inflow and outflow patterns of dialysis fluid, and patient actions to respond to alarms that indicate deviations from the parameters set by the nephrologist. The results of APD+RM show good acceptance by the patient, nephrologists, and nurses, treatment adherence has improved, hospitalizations and technique failure have decreased, and some aspects of quality of life have improved. However, there is a lack of controlled clinical trials that reliably demonstrate lower mortality and comorbidity due to specific causes.

[Factors related to residual renal function loss in patients in peritoneal dialysis]. / Factores relacionados con pérdida de la función renal residual en pacientes en diálisis peritoneal.

BACKGROUND: Residual renal function (RRF) contributes to the quality of life of patients on dialysis. The preservation of RRF is associated with higher patient survival in peritoneal dialysis (PD), and is now accepted that RRF and peritoneal clearance are not of equal value in patient survival. The aim of this study is to know the factors related to RRF loss in prevalent patients in continuous ambulatory peritoneal dialysis (CAPD). METHODS: This is an analysis of secondary outcomes. Forty-three adult patients with type 2 diabetes were included. They had RRF preserved. Clinical and laboratory assessments were done in each visit during a year. RESULTS: The male gender (p = 0.042), systolic (p = 0.009) and diastolic (p = 0.006) blood pressure (BP), hemoglobin (p = 0.008), peritoneal creatinine clearance (p = 0.014), peritoneal ultrafiltration (p = 0.017) and levels of tumor necrosis factor-alpha (TNF-alpha) in plasma (p = 0.022) and dialysate (p = 0.008) were related with RRF loss. CONCLUSIONS: It is important to understand the factors associated with RRF loss in our patients to prevent the gradual loss and its implications on the mortality and quality of life.

Introducción: la conservación de la función renal residual (FRR) en los pacientes en diálisis peritoneal (DP) tiene una clara influencia sobre la calidad de vida, independientemente de que su preservación ha demostrado influir en la mayor supervivencia de los pacientes. El objetivo del presente estudio fue conocer los factores relacionados con pérdida de la FRR en un grupo de pacientes prevalentes en diálisis peritoneal continua ambulatoria (DPCA). Métodos: se trata de un estudio de análisis de resultados secundarios. Se incluyeron 43 adultos con diabetes tipo 2 (DT2), con FRR conservada, a quienes se les dio seguimiento durante un año. Resultados: los factores relacionados con la pérdida de la FRR fueron: género masculino (p = 0.042), presión arterial sistólica (p = 0.009) y diastólica (p = 0.006), hemoglobina (p = 0.008), aclaramiento peritoneal de creatinina (p = 0.014), ultrafiltración (p = 0.017), niveles de factor de necrosis tumoral alfa (FNT­alfa) en plasma (p = 0.022) y dializado (p = 0.008). Conclusiones: es importante conocer los factores relacionados con pérdida de la FRR en nuestros pacientes para evitar la pérdida gradual de la misma y sus implicaciones sobre la mortalidad y calidad de vida.

De novo development of heart valve calcification in incident peritoneal dialysis patients.

BACKGROUND AND AIMS: Cardiac valve calcification (VC) is a frequent complication in chronic kidney disease and is considered a risk factor for all-cause and cardiovascular mortality. However, little is known about the pathophysiology mechanisms that originate it and the factors associated with its development. We undertook this study to analyze the frequency and factors related to de novo development of mitral valve calcification (MVC) and aortic valve calcifications (AVC) in incident peritoneal dialysis (PD) patients. METHODS: A prospective cohort of 124 incident PD patients was studied. Demographic and clinical data were recorded and blood assayed at baseline and after 1 year of follow-up for calcium, phosphorus, glucose, urea, creatinine, cholesterol, triglycerides by spectrophotometry assay; high-sensitivity C-reactive protein (CRP) by immunoturbidimetric ultrasensitive assay, intact parathormone (iPTH) and osteocalcin by electrochemiluminescence, fetuin-A and osteoprotegerin by EDI-ELISA. Valve calcification was evaluated by M-mode bidimensional echocardiogram. RESULTS: Sixty eight percent of patients were male, ages 43 ± 13 years; 51% were diabetic with 1.4 ± 1 months on PD. After 12.3 ± 1 months, 57 patients (46%) developed VC: AVC in 33 (57.8%), MVC in 15 (26.3%) and 9 (15.8%) patients in both valves. There was no correlation between AVC and MCV. In univariate logistic regression analysis, age, diabetes and elevated concentrations of OPG, iPTH and CRP were risk factors for development MVC. In multivariate analysis, only iPTH remained an independent risk factor as was also the case in AVC. CONCLUSIONS: Age, diabetes, osteoprotegerin, parathormone and C-reactive protein are risk factors related to de novo development of MVC and iPTH for AVC in incident dialysis patients.

Cardiovascular and renal effects of bromocriptine in diabetic patients with stage 4 chronic kidney disease.

OBJECTIVE: The objective of this study was to investigate the effect of bromocriptine (BEC) on left ventricular mass index (LVMI) and residual renal function (RRF) in chronic kidney disease (CKD) patients with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS: A 6-month double-blind randomized controlled trial was conducted in 28 patients with T2D and stage 4 CKD with increased LVMI. Fourteen patients received BEC (2.5 mg, initially 1 tablet with subsequent increase to three times a day) and 14 received a placebo (PBO; initially 1 tablet with subsequent increase to three times a day). Cardiovascular changes were assessed by monitoring 24 h ambulatory blood pressure, two-dimensional-guided M-mode echocardiography, and N-terminal brain natriuretic peptide (NT-proBNP) plasma levels. RRF was evaluated by creatinine clearance and cystatin-C plasma levels. RESULTS: Both BEC and PBO groups decreased blood pressure-but the effect was more pronounced in the BEC group. Average 24 h, diurnal and nocturnal blood pressures, and circadian profile showed improved values compared to the PBO group; LVMI decreased by 14% in BEC and increased by 8% in PBO group. NT-proBNP decreased in BEC (0.54 ± 0.15 to 0.32 ± 0.17 pg/mL) and increased in PBO (0.37 ± 0.15 to 0.64 ± 0.17 pg/mL). Creatinine clearance did not change in the BEC group and decreased in the PBO group. CONCLUSIONS: BEC resulted in a decrease on blood pressure and LVMI. BEC also prevented the progression of CKD while maintaining the creatinine clearance unchanged.

Prevalence of chronic kidney disease in an urban Mexican population.

BACKGROUND: The present study was primarily designed to assess the prevalence of chronic kidney disease in a Mexican urban population residing in Mexico and to evaluate certain biologic and socioeconomic conditions as risk factors for the development of renal disease. METHODS: A population-based cross-sectional survey was conducted, which included 3564 patients of either gender aged >18 years, who were randomly selected from lists of patients assigned to primary care facilities in the city of Morelia. A questionnaire about personal current health status, kidney disease, diabetes, hypertension, or heart disease in close relatives, anthropometric and blood pressure measurements, and blood and urine samples to measure glucose, blood urea nitrogen, and creatinine was obtained for each patient. Creatinine clearance (Ccr) was calculated by the Cockcroft-Gault formula. Patients were classified in 1 of the 5 Ccr categories established by the Kidney Disease Outcomes Quality Initiative guidelines. RESULTS: The prevalence rate of Ccr < 15 mL/min was 1142 per million population, and that of Ccr <60 mL/min 80,788 per million population. Alcohol and tobacco consumption, female gender, age >65 years, educational level < primary school, and income < US $4.00/day were significantly associated with reduced Ccr. CONCLUSION: Chronic kidney disease prevalence in this population is similar to that seen in industrialized countries. If these figures are similar to those of the entire Mexican population, only l out of 4 patients requiring renal replacement therapy in the country currently has access to it.