Motivational interviewing promotes adherence and improves wellbeing in pre-dialysis patients with advanced chronic kidney disease.

Low rates of adherence to medical treatments and adverse emotional states are a widespread problem in advanced chronic kidney disease (ACKD). Motivational interviewing using the stages of change model is an effective combination in promoting behavior modifications. The objective of the present study was to determine the effectiveness of an individual, pre-dialysis intervention program (monthly sessions of 90 min over a 6-month period) in terms of adherence, emotional state and health-related quality of life (HRQL). Forty-two patients were evaluated for adherence, depression, anxiety and HRQL with standardized self-report questionnaires. Biochemical markers were also registered. The results show that after the intervention, patients reported significantly higher levels of adherence, lower depression and anxiety levels, and better HRQL (i.e., general health and emotional role domains). Biochemical parameters were controlled significantly better after the intervention, except for iPTH. These findings highlight the potential benefit of applying individual psycho-educational intervention programs based on motivational interviewing and using the stages of change model to promote adherence and wellbeing in ACKD patients.

Bowel bacterial overgrowth as another cause of malnutrition, inflammation, and atherosclerosis syndrome in peritoneal dialysis patients.

Bowel bacterial overgrowth syndrome (BBOS) is an important cause of gastrointestinal (GI) abnormalities. Proinflammatory cytokines (PICs) are excessively produced and accumulate because of kidney failure in dialysis patients who experience chronic infections such as BBOS. We explored the association between GL function, BBOS, and the malnutrition, inflammation, and atherosclerosis (MIA) syndrome. We studied GI malabsorption and maldigestion by analyzing fecal starch, sugar, fat, and nitrogen; intestinal protein permeability (alpha1-antitrypsin fecal clearance); and fecal chymotrypsin. We evaluated BBOS by breath hydrogen test (BHT) after a 3-day fat-and-carbohydrate-overload diet. Positive BHT was present in 10 patients, showing a high prevalence of GI macronutrient malabsorption and maldigestion, and compared with the other patients, the highest plasma levels of tumor necrosis factor alpha and interleukin 6 and lower levels of albumin and prealbumin. Those 10 patients were treated with a combination of several antibiotics, including neomycin, amoxicillin-clavulanate, and quinolones. Between 2 and 3 months later, the BHT, markers of nutrition, and PIC were re-tested. All treated patients showed an improvement in nutrition status and a lesser inflammatory pattern. The BBOS infectious process is found frequently in dialysis patients in association with GI malabsorption and maldigestion, malnutrition, and systemic inflammation. Hyperproduction of PIC because of BBOS induces MIA through a double pathway: GI disorders and deleterious systemic effects.

Risk of technique failure and death in fungal peritonitis is determined mainly by duration on peritoneal dialysis: single-center experience of 24 years.

Fungal peritonitis (FP) is an infrequent cause of peritonitis in peritoneal dialysis (PD), but it has high morbidity and mortality. We analyzed the experience with FP in a single PD unit over a 24-year period. We identified 671 episodes of peritonitis that occurred in 496 patients during the study period. Of these episodes, 23 (3.4%) were FP episodes occurring in 21 patients. In the FP episodes, the patients' mean time on PD was 29.2 +/- 27 months. In 5 episodes, the patients had experienced a peritonitis episode within the preceding month, and in 11 episodes, the patients had used antibiotics within the preceding month. The FP diagnosis was made a mean of 3.17 +/- 3 days after the diagnosis of peritonitis, and in 1 patient, the diagnosis was made after death. Candida spp. were isolated in 82.6% of patients. In 91.3%, the peritoneal catheter was removed. After the FP diagnosis, 15 patients dropped out of PD, but in only 8 patients (34.7%) was drop-out related to FP. In 4 patients, drop-out occurred because of peritoneal membrane failure, and 4 patients (17.4%) died. Time on PD was significantly higher in the group of patients that dropped out of PD because of the FP (45.7 +/- 31 months vs. 19 +/- 18 months, p = 0.02). Fungal peritonitis is a rare cause of peritonitis in PD patients, but it is associated with high morbidity and mortality. Longer time on PD is the main factor in technique failure and mortality.

Gastrointestinal and pancreatic function in peritoneal dialysis patients: their relationship with malnutrition and peritoneal membrane abnormalities.

BACKGROUND: Malnutrition is frequent in peritoneal dialysis (PD) patients, but the contribution of gastrointestinal (GI) dysfunction has not been well established. METHODS: We studied GI function in 49 stable PD patients to ascertain its relationship with malnutrition. After an overload fat diet, fecal fat, sugar, starch and nitrogen, intestinal protein permeability (alpha(1)-antitrypsin fecal clearance [C-alpha(1)-AT]), fecal chymotrypsin (CT), GI hormones and gastrin, pepsinogen I and II, cholecystokinin (CCK), gastrin releasing peptide (GRP), and neuropeptide Y (NPY) were measured. Vasoactive intestinal polypeptide (VIP), substance P (SP), and tumor necrosis factor (TNF-alpha) and biochemical nutritional markers were evaluated. RESULTS: All patients showed high fecal sugar. Elevated fecal nitrogen was found in 21 patients, 6 with high C-alpha(1)-AT. High fecal starch levels appeared in 21, fat in 20, and low fecal CT in 39 patients. These determinations showed inverse relation with nutritional markers. Increased fecal C-alpha(1)-AT values were associated with lower serum albumin. Fecal CT values showed a negative linear correlation with serum albumin and were inversely associated with retinol-binding protein, normalized protein nitrogen appearance, and serum iron. High plasma levels of pancreatic stimulating hormones were found: gastrin, CCK, and VIP. These levels were higher in patients with a worse pancreatic exocrine function. Higher values of other GI hormones, gastrin, pepsinogen I and II, CCK, GRP, and TNF-alpha. Normal concentrations of NPY, VIP, and PS were observed. CONCLUSION: GI abnormalities (malabsorption, maldigestion, pancreatic dysfunction, and protein losing enteropathy) are present in an important number of PD patients. These features are negatively associated to nutrition.

Thirty years in a peritoneal dialysis unit: long-term survival.

INTRODUCTION: Peritoneal dialysis (PD) is an established renal replacement therapy technique which thanks to the technological and clinical advances has improved its survival rates in recent years. OBJECTIVES: The aim of this study was to evaluate patient and technique survival in PD over 30 years, according to the different decades in order to consolidate its usefulness in healthcare. METHOD: Retrospective cohort study including all patients in the PD programme of the Hospital Universitario La Paz (Madrid), from 1980 to 2010. Demographic and clinical variables were collected from medical records. RESULTS: A total of 667 patients were included, 54.4% male, with a mean age of 51.47 years and a median follow-up period of 23.1 months. There was a progressive increase in PD incident patients, especially in automated PD (APD). Patient survival at 5 years was 54%, with a median of 64.66 months, increasing significantly in the last decade (P=.000). Age, comorbidity, male sex, chronic ambulatory PD (CAPD) and diabetes were predictors of patient survival. Technique survival at 5 years was 64.2% with a median of 82 months. The success of the technique was greater in younger patients on APD and with lower comorbidity. CONCLUSIONS: Over 30 years, we found an increase in incident patients. Age, comorbidity and diabetes still continue to be the main determining factors for survival.

Experiencia de 30 años en una unidad de diálisis peritoneal: supervivencia a largo plazo / Thirty years in a peritoneal dialysis unit: long-term survival

INTRODUCCIÓN: La diálisis peritoneal (DP) es una técnica establecida de tratamiento renal sustitutivo que gracias a los avances tecnológicos y clínicos ha mejorado sus tasas de supervivencia en los últimos años. OBJETIVOS: Evaluar la supervivencia del paciente y la técnica en DP a lo largo de 30 años y según las décadas para consolidar su utilidad sanitaria. MÉTODOS: Estudio retrospectivo de cohorte de todos los pacientes del programa de DP del Hospital Universitario La Paz (Madrid) desde 1980 a 2010. Variables demográficas y clínicas fueron recolectadas de los registros clínicos. RESULTADOS: Se incluyeron 667 pacientes, 54,4 % varones, con edad media de 51,47 años y una mediana de seguimiento de 23,1 meses. Se observó un aumento progresivo de pacientes incidentes, especialmente en DP automatizada (DPA). La supervivencia del paciente a 5 años fue de 54 %, con una mediana de 64,66 meses, con un aumento significativo en la última década (p = 0,000). La edad, la comorbilidad, el sexo masculino, la DP crónica ambulatoria (DPCA) y la diabetes fueron predictores de la supervivencia del paciente. La supervivencia de la técnica a los 5 años fue del 64,2 % y la mediana de 82 meses. El éxito de la técnica fue mayor en jóvenes, en DPA y con menor comorbilidad

BACKGROUND AND OBJECTIVE: Peritoneal dialysis (PD) is an establish renal replacement therapy that has evolved in the last decades thanks to technological and clinical advances showing improving survival rates. The aim of this study was to evaluate the patient and technique survival in PD over 30 years of experience and in the different decades. PATIENTS AND METHOD: Retrospective cohort study including all patients in the PD unit of the Hospital Universitario La Paz (Madrid), from 1980 to 2010. Demographics and clinical variables were collected from medical records. RESULTS: A total of 667 patients were included, 54.4% males, with a mean age of 51.47 years and a median follow-up of 23.1 months. There was an increased in PD incident patients, especially in automatic PD (APD). Patient survival at 5 years was 54%, with a median of 64.66 months, increasing significantly in the last decade (p = 0.000). Age, comorbidity, male sex, chronic ambulatory PD and diabetes were independently predictor of patient survival. Technique survival at 5 years was 64.2% and median 82 months. Younger patients, in APD and with less comorbity showed better technique survival. CONCLUSIONS: Over 30 years of experience we found an increased in incident patients. Age, comorbidity and diabetes were still the main predictors of survival

Eating behavior disorders in uremia: a question of balance in appetite regulation.

Eating and appetite disorders are frequent complications of the uremic syndrome which contribute to malnutrition in dialysis patients. The data suggest that uremic anorexia may occur with or without abdominal and visceral fat accumulation despite a lower food intake. This form of obesity (i.e., with low food intake and malnutrition) is more common in dialysis patients than obesity with high food intake. This article reviews the current knowledge regarding mechanisms responsible for appetite regulation in normal conditions and in uremic patients. Anorexia in dialysis patients has been historically considered as a sign of uremic toxicity due to "inadequate" dialysis as judged by uncertain means ("middle molecule" accumulation, Kt/V, "peak-concentration hypothesis," and others). We propose the tryptophan-serotonin hypothesis, based on a uremia-induced disorder in patients' amino acid profile--low concentrations of large neutral and branched-chain amino acids with high tryptophan levels. A high rate of tryptophan transport across the blood-brain barrier increases the synthesis of serotonin, a major appetite inhibitor. Inflammation may also play a role in the genesis of anorexia and malnutrition. For example, silent infection with Helicobacter pylori may be a source of cytokines with cachectic action; its eradication improves appetite and nutrition. The evaluation of appetite should take into account cultural and social aspects. Uremic patients showed a universal trend to carbohydrate preference and red meat refusal compared to healthy people. In contrast, white meat was less problematic. Uremic patients also have a remarkable attraction for citrics and strong flavors in general. Eating preferences or refusals have been related to the predominance of some appetite peptide modulators. High levels of cholecystokinin (CCK) (a powerful anorexigen) are associated with early satiety for carbohydrates and neuropeptide Y (NPY) (an orexigen) with repeated food intake. Obesity and elevated body mass index often falsely suggest a good nutritional status. In uremic patients (a hyperinsulinemia state), disorders in the regulation of fat distribution (insulin, leptin, insulin-like growth factor [IGF]-1, fatty acids, and disorders in receptors for insulin, lipoprotein lipase, mitochondrial uncoupling protein-2, and beta 3 adrenoreceptors) may cause abdominal fat accumulation without an increase in appetite. Finally, appetite regulation in uremia is highly complex. Disorders in adipose tissue, gastrointestinal and neuropeptides, retained or hyperproduced inflammatory end products, and central nervous system changes may all play a role. Uremic anorexia may be explained by a hypothalamic hyperserotoninergic state derived from a high concentration of tryptophan and low branched-chain amino acids.

Estudio del autocuidado en los pacientes de Diálisis Peritoneal / Study of the self-care in patinets in peritoneal dialysis

Uno de los grandes retos de la enfermería nefrológica es el incremento de pacientes mayores de 65 años que se incluyen actualmente en los programas de diálisis peritonal. El objetivo de este trabajo es describir, evaluar y valorar los factores edad, autocuidado, carga familiar y tiempo de tratamiento de estos pacientes. Las enfermeras de 15 unidades de diálisis peritoneall cumplimentaron cuestionarios referidos a 300 pacientes. De los resultados cabe destacar que la edad es un factor significativo en el deterioro del autocuidado, del incremento de la sobrecarga familiar y de las cargas de trabajo de enfermería (AU)