Risk factors and etiological characteristics of urinary tract infection in hospitalized continuous ambulatory peritoneal dialysis patients.

OBJECTIVE: This study aimed to explore the risk factors and etiological characteristics of urinary tract infection (UTI) in continuous ambulatory peritoneal dialysis (CAPD) patients. PATIENTS AND METHODS: A total of 90 CAPD patients with UTI comprised the infection group, while 32 CAPD patients without UTI constituted the control group. The risk factors and etiological characteristics of UTI were analyzed. RESULTS: Of the 90 bacterial strains isolated, 30 were Gram-positive (33.3%) and 60 were Gram-negative (66.7%). Urinary stones or urinary tract structural changes were more prevalent in the infection group (71.1%) than in the control group (46.9%) (χ² = 6.076, p = 0.018). The proportion of patients with residual diuresis less than 200 ml was higher in the infection group (50%) than in the control group (15.6%) (χ² = 11.533, p = 0.001). The distribution of primary disease differed between the two groups. Patients in the infection group had higher CAPD vintage, levels of triglycerides, fasting blood glucose, blood creatinine, blood phosphorus, and calcium-phosphorus product than those in the control group. Multivariate binary logistic regression analysis indicated that residual diuresis less than 200 ml (OR = 3.519, p = 0.039) and urinary stones or structural changes (OR = 4.727, p = 0.006) were independent risk factors for UTI. CONCLUSIONS: Urine cultures of CAPD patients with UTI contained a complex distribution of pathogenic bacteria. Urinary stones or structural changes and residual diuresis less than 200 ml were independent risk factors for UTI.

Effects of soy isoflavones on serum lipids and lipoprotein (a) in peritoneal dialysis patients.

BACKGROUND AND AIM: Lipid abnormalities are common in peritoneal dialysis (PD) patients and no effective treatment to decrease serum lipoprotein (a) [Lp(a)] in dialysis patients is known so far. Therefore, this research was designed to investigate the effects of soy isoflavone supplement on serum lipids and Lp(a) in PD patients. METHODS & RESULTS: In this randomized, double-blind, placebo-controlled trial, 40 PD patients were randomly assigned to either the isoflavone or the placebo group. The patients in the isoflavone group received 100 mg soy isoflavone daily for 8 weeks, whereas the placebo group received corresponding placebos. At baseline and the end of the 8th week, 7 mL of blood was obtained from each patient and serum triglycerides, total cholesterol, low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), and Lp(a) were measured. Serum Lp(a) reduced significantly up to 10% in the isoflavone group at the end of week 8 compared to baseline (P < 0.05), and the reduction was significant in comparison with the placebo group (P < 0.05). Serum HDL-C increased significantly up to 11.5% in the isoflavone group at the end of week 8 compared to baseline (P = 0.05), and the increment was significant in comparison with the placebo group (P < 0.05). There were no significant differences between the two groups in mean changes of serum triglycerides, total cholesterol, and LDL-C. CONCLUSIONS: This study indicates that daily administration of 100 mg soy isoflavones reduces serum Lp(a) and increases HDL-C concentration which are two determinants of cardiovascular disease in PD patients. CLINICALTRIALS.GOV: NCT03773029. REGISTRATION NUMBER AND DATE: NCT03773029 - 2018.

Effects of parathyroid hormone and vitamin D supplementation on stroke among patients receiving peritoneal dialysis.

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) patients have a high incidence of stroke and commonly have increased parathyroid hormone levels and vitamin D insufficiency. We seek to investigate the incidence of stroke and the role of parathyroid hormone and vitamin D supplementation in stroke risk among CAPD patients. METHODS: This study employed a retrospective design. We enrolled a Chinese cohort of 980 CAPD patients who were routinely followed in our department. The demographic and clinical data were recorded at the time of initial CAPD and during follow-up. The included patients were separated into non-stroke and stroke groups. The effects of parathyroid hormone and vitamin D supplementation on stroke in CAPD patients was evaluated. The primary endpoint is defined as the first occurrence of stroke, and composite endpoint events are defined as death or switch to hemodialysis during follow-up. RESULTS: A total of 757 eligible CAPD patients with a mean follow-up time of 54.7 (standard deviation, 33) months were included in the study. The median incidence of stroke among our CAPD patients was 18.9 (interquartile range, 15.7-22.1) per 1000 person-years. A significant nonlinear correlation between baseline iPTH and hazard of stroke (p-value of linear association = 0.2 and nonlinear association = 0.002) was observed in our univariate Cox regression analysis, and low baseline iPTH levels (≤150 pg/ml) were associated with an increased cumulative hazard of stroke. Multivariate Cox regression analysis indicated a significant interaction effect between age and iPTH after adjusting for other confounders. Vitamin D supplementation during follow-up was a predictive factor for stroke in our cohort. CONCLUSIONS: CAPD patients suffered a high risk of stroke, and lower iPTH levels were significantly correlated with an increased risk of stroke. Nevertheless, vitamin D supplementation may reduce the risk of stroke in these patients.

Benefits of peritoneal ultrafiltration in HFpEF and HFrEF patients.

BACKGROUND: Peritoneal ultrafiltration (pUF) in refractory heart failure (HF) reduces the incidence of decompensation episodes, which is of particular significance as each episode incrementally adds to mortality. Nevertheless, there are insufficient data about which patient cohort benefits the most. The objective of this study was to compare pUF in HFrEF and HFpEF, focusing on functional status, hospitalizations, surrogate endpoints and mortality. METHODS: This study involves 143 patients, who could be classified as either HFpEF (n = 37, 25.9%) or HFrEF (n = 106, 74.1%) and who received pUF due to refractory HF. RESULTS: Baseline eGFR was similar in HFrEF (23.1 ± 10.6 mg/dl) and HFpEF (27.8 ± 13.2 mg/dl). Significant improvements in NYHA class were found in HFpEF (3.19 ± 0.61 to 2.72 ± 0.58, P <  0.001) and HFrEF (3.45 ± 0.52 to 2.71 ± 0.72, P <  0.001). CRP decreased in HFrEF (19.4 ± 17.6 mg/l to 13.7 ± 21.4 mg/l, P = 0.018) and HFpEF (33.7 ± 52.6 mg/l to 17.1 ± 26.3 mg/l, P = 0.004). Body weight was significantly reduced in HFrEF (81.1 ± 14.6 kg to 77.2 ± 15.6 kg, P = 0.003) and HFpEF (86.9 ± 15.8 kg to 83.1 ± 15.9 kg, P = 0.005). LVEF improved only in HFrEF (25.9 ± 6.82% to 30.4 ± 12.2%, P = 0.046). BCR decreased significantly in HFrEF and HFpEF (55.7 ± 21.9 to 34.3 ± 17.9 P > 0.001 and 50.5 ± 68.9 to 37.6 ± 21.9, P = 0.006). Number of hospitalization episodes as well as number of hospitalization days decreased significantly only in HFpEF (total number 2.88 ± 1.62 to 1.25 ± 1.45, P <  0.001, days 40.4 ± 31.7 to 18.3 ± 22.5 days, P = 0.005). CONCLUSIONS: pUF offers various benefits in HFpEF and HFrEF, but there are also substantial differences. In particular, hospitalization rates were found to be significantly reduced in HFpEF patients, indicating a greater medical and economical advantage. However, LVEF was only found to be improved in HFrEF patients. While pUF can now be regarded as an option to supplement classical HF therapy, further studies are desirable to obtain specifications about pUF in HFpEF, HFmEF and HFrEF patients.

Omega-3 in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis, Effects on Inflammatory Markers and Lipid Profile.

INTRODUCTION: CKD is one of the most prevalent entities associated with high morbidity and mortality. Most of the patients with renal diseases, particularly patients undergoing dialysis, suffer from cardiovascular disease and it is necessary to employ appropriate strategies to prevent and manage this complication. The aim of this study was to evaluate the anti-inflammatory effects of omega-3 in patients undergoing CAPD. METHODS: Nineteen CAPD patients with certain inclusion and exclusion criteria enrolled in this study. Omega-3 capsules with a dose of 1 g/d up to three months, were administrated. Some inflammatory markers such as ESR, CRP, HS-CRP, IL-6, MDA, and homocysteine were measured in three phases. In addition, lipid profile including triglyceride, cholesterol, LDL, and HDL were measured. RESULTS: Results of this study showed that CRP, HS-CRP, and homocysteine levels increased insignificantly (P > .05) whereas, MDA level was increased significantly (P < .05). ESR and IL-6 levels both decreased but did not show any statistically significance (P > .05). Results of lipid profile also suggested that none of the lipid levels changed significantly (P > .05). CONCLUSION: It is necessary to design large trials in order to understand clear effects of omega-3 on inflammatory markers in PD patients. In addition, the results of this current pilot study should be interpreted with caution.

[Italian nephrology and the progress of dialysis from its dawn to the present day].

In Italy, over the last 50 years, dialysis has been the driving force of research in nephrology. The work of many Italian nephrologists has fueled progress in dialytic techniques worldwide, improving dramatically the quality of dialytic therapy. Our foreign colleagues unanimously agree that we have been the first to look into the complexities of dialysis, into the many differences between dialytic patients and how to best address this diversity. This has allowed us to adopt a holistic approach, deeply connected to technological innovation, with the aim of putting the patient center stage and creating a "precision dialysis".

Higher serum phosphorus predicts residual renal function loss in male but not female incident peritoneal dialysis patients.

BACKGROUND: Elevated serum phosphorus level is a risk factor for progression of chronic kidney disease in non-dialysis patients. However, the association of serum phosphorus level with residual renal function (RRF) loss among incident continuous ambulatory peritoneal dialysis (CAPD) patients remains unclear. METHODS: We performed a retrospective analysis of prospectively collected cohort of 1245 incident CAPD patients from January 2006 to December 2015 and followed up until December 2017. Patients were stratified into tertiles according to baseline serum phosphorus levels. RRF loss was defined as residual glomerular filtration rate (mL/min/1.73 m2) reaching zero or estimated urine output less than 200 mL/day on two successive clinic visits. Propensity-score matched Cox's proportional hazards and competing risk models were performed to examine the association of serum phosphorus with RRF loss. RESULTS: A total of 421 (33.82%) patients had loss of RRF over a median follow-up of 26.23 months. In the entire cohort, elevated serum phosphorus was associated with increased risk for RRF loss after adjustment. In the propensity-score matched cohort, patients in the 3rd tertile of serum phosphorus had a 51% higher risk of RRF loss than those in the combination of the 1st and 2nd tertiles. Furthermore, the association of serum phosphorus level with RRF loss differed by sex (interaction P = 0.018). The adjusted HRs per 1 mg/dL increase in serum phosphorus level of RRF loss were 1.32 (95% CI 1.15-1.50, P < 0.001) for male and 1.03 (95% CI 0.87-1.21, P = 0.750) for female, respectively. These findings persisted in competing risk analysis. CONCLUSION: Higher serum phosphorus levels independently predicts RRF loss in men treated with CAPD.

Home-based training using neuromuscular electrical stimulation in patients on continuous ambulatory peritoneal dialysis: A pilot study.

There is ample evidence that maintenance of basic physical fitness through exercise training is crucial for patients with chronic renal insufficiency. Rehabilitation based on neuromuscular electrical stimulation (NMES) of thigh muscles has been shown to have many beneficial effects in patients with chronic diseases. It is likely that NMES could have beneficial effects also in patients on chronic ambulatory peritoneal dialysis (CAPD). NMES was applied for 20 weeks to 14 patients on CAPD, mean age 61.9 (8.7) years, using battery-powered stimulators (CEFAR-REHAB X2; Sweden) and self-adhesive electrodes 80 × 130 mm (PALS Platinum; Denmark). Stimulation characteristics: biphasic current, pulse width 400 µs, 8 seconds contraction-12 seconds relaxation, frequency modulation 40-60 Hz, and maximal intensity 60 mA. NMES was home-based and applied simultaneously to quadriceps muscles of both legs (2 × 30 min/day). Functional performance, muscle power (Fmax ), arterial stiffness (assessed by cardio-ankle vascular index-CAVI), and quality of life by KDQOL-SF evaluation was done at baseline and at the end of program. Home NMES improved significantly the main functional parameters: VO2peak /kg increased by +2.2 (1.6) mL O2 /kg/min (P < 0.002), peak workload by +0.1 (0.1) W/kg (P < 0.005), and distance walked in 6 MWT by +44.7 (58.4) m (P < 0.008). Only insignificant changes were observed in CAVI and Fmax . KDQOL-SF analysis showed significant improvement in seven parameters of QoL (P < 0.012-0.049). This pilot study is the first clinical report dealing with the use of NMES in patients on CAPD. The results demonstrate that an improvement of exercise capacity and QoL can be achieved by home-based NMES in CAPD patients.

Recirculating peritoneal dialysis system using urease-fixed silk fibroin membrane filter with spherical carbonaceous adsorbent.

The chronic kidney disease (CKD) patients are undergoing continuous ambulatory peritoneal dialysis (CAPD). However, there are some constraints, the frequent exchange of the dialysate and limitation of outside activity, associated with CAPD remain to be solved. In this study, we designed the wearable artificial kidney (WAK) system for peritoneal dialysis (PD) using urease-immobilized silk fibroin (SF) membrane and polymer-based spherical carbonaceous adsorbent (PSCA). We evaluated this kit's removal abilities of uremic toxins such as urea, creatinine, uric acid, phosphorus, and ß2-microglobulin from the dialysate of end-stage renal disease (ESRD) patients in vitro. The uremic toxins including urea, creatinine, uric acid, and phosphorus were removed about 99% by immobilized SF membrane and PSCA filter after 24 h treatment. However, only 50% of ß2-microglobulin was removed by this filtering system after 24 h treatment. In vivo study result shows that our filtering system has more uremic toxins removal efficiency than exchanged dialysate at every 6 h. We suggest that recirculating PD system using urease-immobilized SF membrane with PSCA could be more efficient than traditional dialysate exchange system for a WAK for PD.

Clinical efficacy and feasibility of whey protein isolates supplementation in malnourished peritoneal dialysis patients: A multicenter, parallel, open-label randomized controlled trial.

BACKGROUND AND AIMS: Poor dietary intake is commonly associated with malnutrition in the dialysis population and oral nutritional supplementation is strategized to redress dietary inadequacy. Knowledge on clinical efficacy of whey protein supplementation (WPS) as an option to treat malnutrition in continuous ambulatory peritoneal dialysis (CAPD) patients is limited. METHODS: This multicenter, parallel, open-label, randomized controlled trial investigated the clinical efficacy of WPS in 126 malnourished CAPD patients with serum albumin <40 g/L and body mass index (BMI) <24 kg/m2. Patients randomized to the intervention group (IG, n = 65) received protein powder (27.4 g) for 6 months plus dietary counseling (DC) while the control group (CG, n = 61) received DC only. Anthropometry, biochemistry, malnutrition-inflammation-score (MIS), dietary intake inclusive of dialysate calories, handgrip strength (HGS) and quality of life (QOL) were assessed at baseline and 6 months. Clinical outcomes were assessed by effect size (Cohen's d) comparisons within and between groups. RESULTS: Seventy-four patients (n = 37 per group) completed the study. Significantly more IG patients (59.5%) achieved dietary protein intake (DPI) adequacy of 1.2 g/kg per ideal body weight (p < 0.001) compared to CG (16.2%) although difference in the adequacy of dietary energy intake between groups was non-significant (p > 0.05). A higher DPI paralleled significant increases in serum urea (mean Δ: IG = +2.39 ± 4.36 mmol/L, p = 0.002, d = 0.57 vs CG = -0.39 ± 4.59 mmol/L, p > 0.05, d = 0.07) and normalized protein catabolic rate, nPCR (mean Δ: IG = +0.11 ± 0.14 g/kg/day, p < 0.001, d = 0.63 vs CG = +0.001 ± 0.17 g/kg/day, p > 0.05, d = 0.09) for IG compared to CG patients. Although not significant, comparison for changes in post-dialysis weight (mean Δ: +0.64 ± 1.16 kg vs +0.02 ± 1.36 kg, p = 0.076, d = 0.58) and mid-arm circumference (mean Δ: +0.29 ± 0.93 cm vs -0.12 ± 0.71 cm, p = 0.079, d = 0.24) indicated trends favoring IG vs CG. Other parameters remained unaffected by treatment comparisons. CG patients had a significant decline in QOL physical component (mean Δ = -6.62 ± 16.63, p = 0.020, d = 0.47). Using changes in nPCR level as a marker of WPS intake within IG, 'positive responders' achieved significant improvement in weight, BMI, skinfold measures and serum urea (all p < 0.05), while such changes within 'negative responders' were non-significant (all p > 0.05). CONCLUSION: A single macronutrient approach with WPS in malnourished CAPD patients was shown to achieve DPI adequacy and improvements in weight, BMI, skin fold measures, serum urea and nPCR level. CLINICAL TRIAL REGISTRY: www.clinicaltrials.gov (NCT03367000).

Routine Monitoring of Sodium and Phosphorus Removal in Peritoneal Dialysis (PD) Patients Treated with Continuous Ambulatory PD (CAPD), Automated PD (APD) or Combined CAPD+APD.

BACKGROUND: Adequate removal of sodium (Na) and phosphorus (P) is of paramount importance for patients with dialysis-dependent kidney disease can easily quantified in peritoneal dialysis (PD) patients. Some studies suggest that automated PD (APD) results in lower Na and P removal. METHODS: In this study we retrospectively analysed our data on Na and P removal in PD patients after implementation of a routine monitoring in 2011. Patients were stratified in those treated with continuous ambulatory PD (CAPD, n=24), automated PD (APD, n=23) and APD with one bag change (CAPD+APD, n=10). Until 2015 we collected time-varying data on Na and P removal from each patient (median 5 [interquartile range 4-8] values). RESULTS: Peritoneal Na and P removal (mmol per 24h ± standard deviation) was 102 ± 48 and 8 ± 2 in the CAPD, 90 ± 46 and 9 ± 3 in the APD and 126 ± 39 and 13 ± 2 in the CAPD+APD group (ANOVA P=0.141 and <0.001). Taking renal excretion into account total Na and P removal (mmol per 24h) was 221 ± 65 and 16 ± 5 in the CAPD, 189 ± 58 and 17 ± 6 in the APD and 183 ± 38 and 16 ± 6 in the CAPD+APD group (P=0.107 and 0.764). Over time, peritoneal removal of Na but not that of P increased in all groups. In patients with modifications of PD treatment, Na but not P removal was significantly increased over-time. CONCLUSIONS: Overall Na and P removal were similar with different PD modalities. Individualized adjustments of PD prescription including icodextrin use or higher glucose concentration can improve Na removal while P removal is mainly determined by the dialysate volume.

Factors effective on peritoneal phosphorus transport and clearance in peritoneal dialysis patients
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AIMS: Transport characteristics of phosphorus are different from other small solutes that are evaluated in routine peritoneal equilibration test (PET) in peritoneal dialysis (PD) patients. We aimed to evaluate peritoneal phosphorus clearance and permeability, and their relationship with peritoneal membrane transport type and creatinine clearance as well as factors affecting peritoneal phosphorus clearance. METHODS: 70 adult patients on a PD program were included in our study. Phosphorus transport status was classified according to dialysate/plasma (D/P) phosphorus at the 4th hour of PET as slow transporter (< 0.47), slow-average transporter (0.47 - 0.56), fast-average transporter (0.57 - 0.67), and fast transporter (> 0.67). We evaluated the relationship of peritoneal phosphorus clearance and transport type with PD regime, phosphorus level, and presence of residual renal function in addition to investigating factors that are effective on peritoneal phosphorus clearance. RESULTS: D/P phosphorus and peritoneal phosphorus clearance were positively correlated with D/P creatinine and peritoneal creatinine clearance, respectively. Automated PD and continuous ambulatory PD patients were similar regarding phosphorus and creatinine clearances and transport status based on D/P phosphorus. The major determinant of peritoneal phosphorus clearance was anuria status. Anuric patients had higher dialysate volume (11.6 ± 3.0 L vs. 8.4 ± 2.1 L, p < 0.001) and therefore higher peritoneal phosphorus clearance (61.7 ± 15.1 L/week/1.73 m2 vs. 48.4 ± 14.0 L/week/1.73 m2, p = 0.001). Hyperphosphatemia was present in 40% and 11% of anuric patients and those with residual renal function, respectively (p = 0.005). CONCLUSIONS: Peritoneal phosphorus transport characteristics are similar to that of creatinine. Although increased dialysis dose may increase peritoneal phosphorus clearance, it may be insufficient to prevent hyperphosphatemia in anuric patients.
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Comparative Study on Trace Element Excretions between Nonanuric and Anuric Patients Undergoing Continuous Ambulatory Peritoneal Dialysis.

Few studies have been reported on alterations of trace elements (TE) in peritoneal dialysis patients. Our objective was to investigate and assess the characteristics of daily TE excretions in continuous ambulatory peritoneal dialysis (CAPD) patients. This cross-sectional study included 61 CAPD patients (nonanuric/anuric: 45/16) and 11 healthy subjects in Wuhan, China between 2013 and 2014. The dialysate and urine of patients and urine of healthy subjects were collected. The concentrations of copper (Cu), zinc (Zn), selenium (Se), molybdenum (Mo), and arsenic (As) in dialysate and urine were determined using inductively coupled plasma mass spectrometer (ICP-MS). Various clinical variables were obtained from automatic biochemical analyzer. Daily Cu, Zn, Se, and Mo excretions in nonanuric patients were higher than healthy subjects, while arsenic excretion in anuric patients was lower. A strong and positive correlation was observed between Se and Mo excretion in both dialysate (ß = 0.869, p < 0.010) and urine (ß = 0.968, p < 0.010). Furthermore, the clinical variables associated with Se excretion were found to be correlated with Mo excretion. Our findings indicated that nonanuric CAPD patients may suffer from deficiency of some essential TEs, while anuric patients are at risk of arsenic accumulation. A close association between Se and Mo excretion was also found.

The influence of low calcium dialysate on left ventricular diastolic function in peritoneal dialysis patients.

Left ventricular (LV) diastolic function was found to be a significant predictor of cardiovascular events and general mortality in dialysis. Studies have indicated that dialysate calcium concentrations were significantly associated with cardiac function. However, the relationship between low calcium dialysate and LV diastolic function has not been clear. The aim of this study was to investigate the influence of low calcium dialysate on cardiac function in peritoneal dialysis (PD) patients. A total of 60 PD patients were enrolled in this study, with a calcium content of the PD solution of 1.25 mmol/L in 30 patients (low-calcium group) and 1.75 mmol/L in 30 patients (standard-calcium group). Standard M-mode and two-dimensional ultrasound measurements were applied to detect the cardiac function. After 12-month follow-up, we found no significant difference in blood pressure, calcium, phosphorus, parathyroid hormone (PTH), etc., between the two groups. Residual renal function (RRF), which is associated with LV cardiac function, was significantly decreased in the standard-calcium group compared with the low-calcium group (5.64 ± 3.23 vs. 9.38 ± 3.17, p = .001). Compared with the low-calcium group, Emax (peak early diastolic velocity) and Amax (peak late diastolic velocity) were significantly decreased (p < .05), whereas myocardial performance index (MPI) was obviously increased in standard-calcium group (9.69 ± 2.71 vs. 7.75 ± 0.93, p < .05). In conclusion, our data suggest that low calcium dialysate treatment is significantly associated with better LV diastolic function.

Monitored anesthesia care based on ultrasound-guided subcostal transversus abdominis plane block for continuous ambulatory peritoneal dialysis catheter surgery: case series.

Planning safe perioperative management for patients undergoing continuous ambulatory peritoneal dialysis (CAPD) catheter surgery (insertion and extraction of the catheter) is often difficult because many of these patients not only have renal insufficiency but also have co-existing disorders, such as heart diseases. As increased indications for perioperative anticoagulation therapy have limited the choice of anesthesia, selecting an appropriate anesthetic method, particularly for patients with poor systemic conditions, is becoming more challenging. We report seven cases of CAPD catheter surgery successfully managed by monitored anesthesia care using subcostal transversus abdominis plane (TAP) block with additional local anesthetic infiltration and analgesics. Despite co-existing cardiac disease and/or coagulation disorders, all patients were safely managed without any other major anesthetic methods. Subcostal TAP block is a useful anesthetic option for CAPD catheter surgery, particularly for patients with poor systemic conditions and/or in whom neuraxial blocks are contraindicated.

Denial Defense Mechanism in Dialyzed Patients.

BACKGROUND: It is a struggle to identify the most adaptive coping strategies with disease-mediated stress. Here, we hypothesize that intensity of coping strategies, including denial, in patients with end-stage renal disease (ESRD), varies with type of renal replacement therapy (RRT). MATERIAL AND METHODS: We enrolled 60 in-center hemodialyzed patients (HD) and 55 patients treated with continuous ambulatory peritoneal dialysis (CAPD). We administered the Coping Inventory with Stressful Situation, Profile of Mood States, and Stroop Anxiety Inventory to measure patient coping strategies in the context of their ESRD. Denial defense mechanism was measured via the IBS-R/ED. The Nottingham Health Profile was used to evaluate self-perceived quality of life. Serum potassium, urea, creatinine, phosphorus, calcium, albumin, and hematocrit were utilized as the measurements of adequacy of dialysis. RESULTS: HD patients had higher self-reported intensity of denial mechanism and avoidance-oriented strategies versus CAPD patients. Because a single strategy is almost never employed, we conducted cluster analysis. We identify 3 patterns of coping strategies using cluster analysis. "Repressors" employed denial and avoidance strategies and were predominant in HD. The second cluster consists of subjects employing predominantly task-oriented strategies with equal distribution among dialyzed patients. The third cluster encompassed a small group of patients who shared higher intensity of both denial and task-oriented strategies. Health-related outcome, anxiety, and mood profile were similar across all patients. CONCLUSIONS: HD patients predominantly used "repressive" strategies. Patients on RRT utilized denial and avoidance-based strategies to achieve satisfactory outcome in terms of perceived quality of life. We conclude that these coping mechanisms that were previously thought to be inferior are beneficial to patient compliance with RRT.

Randomized, double-blind, placebo-controlled trial of spironolactone for hypokalemia in continuous ambulatory peritoneal dialysis patients.

The incidence of hypokalemia in continuous ambulatory peritoneal dialysis (CAPD) patients is about 15-60%, leading to significant complications. There is no standard treatment other than potassium supplement in this setting. The aim of this study was to evaluate effect of spironolactone 25 mg/day in CAPD patients who have a history of hypokalemia. This is a randomized, double-blind, placebo-controlled, cross-over study in CAPD patients who had a history of hypokalemia. Study intervention is 4 weeks of oral spironolactone 25 mg/day or placebo, cross-over after a 2-week wash-out period. The primary outcome was the difference of serum potassium before and after 4 weeks of spironolactone treatment. Serum potassium was measured every 2 weeks, serum magnesium, urine and peritoneal fluid potassium measured before and after each treatment period. We enrolled 24 patients, and 20 completed the cross-over study. Ten patients were anuric. The total doses of potassium supplement were the same during the study period. Serum potassium levels before and after study intervention were not significantly different in both groups (4.23 ± 0.64 vs. 3.90 ± 0.59 mEq/L for spironolactone P = 0.077 and 3.84 ± 0.62 vs. 3.91 ± 0.52 for placebo P = 0.551). Total 24-h potassium, magnesium, sodium excretion, urine volume and ultrafiltration volume were not affected by spironolactone or placebo. There was one episode of hyperkalemia (5.6 mEq/L) during the spironolactone treatment period. Spironolactone 25 mg/day does not have a significant effect on serum potassium or urine and peritoneal excretion rate in CAPD patients who have a history of hypokalemia.