The continuum home program concept.

The continuum home program concept aims to promote preservation of freedom for the individual patient, providing the opportunity to administer the therapy of choice in the patient's own environment. It strives for a continuation rather than a disruption of the patient's live. Continuum emphasizes matching the prescription to the patient's metabolic and psychological needs and strong consideration is given to economic realities and the best utilization of resources. Patients should be approached from the time of earliest referral and should be followed throughout their life with renal failure, regardless of therapy selection. The concept incorporates the traditional renal team members, as well as individuals responsible for the creation, manufacturing and delivery of products and services. It addresses patient recruitment, pre-ESRD education, general planning of dialysis, training tools and the timely creation of vascular or peritoneal access. The ideal program should provide a continuous flow of services where consideration for the patient's autonomy is always a priority.

Prescription writing: CAPD and PD plus.

The formulations of prescriptions for CAPD and PD plus are based on the theoretical constructs of equilibration dialysis and automated PD. There is good correlation between the predicted clearances and net ultrafiltration and those observed in clinical practice, particularly for patients with average peritoneal transport. Higher dialysate flows prescribed during APD to enhance small solute clearances and net ultrafiltration often result in reduced sodium removal due to sodium sieving. Sodium sieving can be minimized with APD through optimal prescriptions. The evidence supports the use of PD plus when adequacy targets cannot be achieved with CAPD.

Complications of peritoneal dialysis catheters: early and late.

The complications of peritoneal dialysis catheters are often due to errors made during the initial catheter insertion procedure. Other complications relate to the improper selection of the catheter type or size. Thus, many complications are preventable. This review summarizes the complications resulting from the insertion or presence of a PD catheter and classifies them as either early or late events. A short comment on early diagnosis and appropriate management is also provided.

Peritoneal dialysis solutions--at a crossroad.

After many decades of evolution and with many choices available for the formulation of peritoneal dialysis fluids (PDF), we find ourselves at a crossroads. A review of related developments, laboratory trials and clinical evaluations is offered to stimulate future research in this area. The information presented here raises more questions than it provides answers, but opens the door to innumerable possibilities for improvement. The search for a biocompatible osmotic agent designed to replace those currently used has been frustrating and is far from being considered a success. Research on cytokines and other mediators of inflammation produced a huge amount of interesting scientific knowledge that may help our understanding. However, it is unlikely that it will identify a specifically targeted anticytokine, or combination of them, designed to neutralize and/or reverse inflammatory changes resulting from the use of poorly biocompatible PDF. The development of low glucose degradation product (GDP) solutions by means of multi-chambered bags appear to be a step in the right direction and perhaps is the most significant improvement in this field in many decades. GDPs are important, but not the only offenders or the exclusive source of oxidative stress. Thus, the addition of antioxidants to PDF formulations, in our opinion, deserves further consideration. Additionally, repopulation of the mesothelial monolayer by means of periodic autotransplantation of mesothelial cells may well become a useful tool to prevent and/or correct membrane failure. We are fortunate to have choices at this crossroad, which we must evaluate rigorously.

Dialysis of schizophrenic patients: a double-blind study.

The authors designed a double-blind hemodialysis protocol consisting of hemodialysis or sham dialysis twice weekly for 10 weeks, respectively. Four patients were carefully selected and evaluated clinically and on the Clinical Global Impression Scale. Three did not show any signs of improvement, and one patient demonstrated questionable improvement but decompensated after 12 additional weeks of hemodialysis. This preliminary study does not confirm the hypothesis that hemodialysis is effective in controlling psychotic symptoms. The authors consider other possibly beneficial treatments for schizophrenia.

Idiopathic late-onset immunoglobulin deficiency. Clinical observations in 50 patients.

Fifty patients with late-onset idiopathic immunoglobulin deficiency were studied and the frequency of various clinical associations and complications was observed. Men and women were equally affected, although the age at onset in men peaked in the third decade whereas it was more uniformly distributed in women. Sinobronchopulmonary infections were common and were caused by Haemophilus influenzae. Diplococcus pneumoniae, Streptococcus pyogenes and Staphylococcus aureus: bronchiectasis occurred in 28 per cent. Thirty patients (60 per cent) had diarrhea, which was often associated with steatorrhea, giardiasis, achlorhydria, abnormal Schilling tests and morphologic abnormalities on small bowel biopsy specimens, including nodular lymphoid hyperplasia; three patients had pernicious anemia. In the 20 patients without diarrhea these abnormalities were not observed except for giardiasis in one patient and achlorhydria in two patients. Cholelithiasis occurred in both groups in about a third of the patients tested. A high degree of susceptibility to neoplasia was noted. Thyroid abnormalities, including primary hypothyroidism and Graves' disease, were observed in six patients. Additional occasional findings were vitiligo, keratoconjunctivitis sicca and arthritis. Splenomegaly occurred in 14 (28 per cent) patients. The percentage of B lymphocytes in the blood was determined in 10 patients; it was normal or slightly decreased in eight patients and low in two patients.

Daily and nocturnal hemodialysis: how do they stack up?

A growing number of articles in the literature describe experiences using more frequent hemodialysis (HD), either short daily or long nocturnal. Most of these publications highlight successes obtained by these programs with a fragmented look at specific areas and outcomes. This review of published results from the use of these therapies shows that universal improvement is noted in dialysis adequacy, nutrition, quality of life, blood pressure control, fluid and electrolyte balance, and hospitalizations when these parameters are mentioned. However, data reporting is often incomplete. Most studies do not have adequate control groups, patient populations are often different from the standard HD population, and many have small numbers that preclude statistical significance. Nonuniformity of patient selection and study design prevents accurate comparison and pooling of patient data. In some cases, the same patients' data for the same periods of observation are reported in several studies. Despite data that can be characterized as preliminary and anecdotal, the results reported in this review show remarkable patient improvement worthy of serious consideration by the renal community. To reach a level of evidence that will be widely acceptable, the renal community needs to partner with such government institutions as the National Institutes of Health and the Health Care Financing Administration to study systematically the outcomes and costs associated with using more frequent HD. In the process, important ramifications of such a cooperative study, including potential changes in policy, need to be considered.

Quality-of-life evaluation using Short Form 36: comparison in hemodialysis and peritoneal dialysis patients.

Short Form 36 (SF-36) is a well-documented health-related quality-of-life (HRQOL) instrument consisting of 36 questions compressed into eight scales and two primary dimensions: the physical and mental component scores. This tool was used to evaluate QOL among peritoneal dialysis (PD) and hemodialysis (HD) patients. The results of 16,755 HD and 1,260 PD patients (728 continuous ambulatory PD [CAPD] and 532 continuous cycling PD [CCPD]) completing an SF-36 during 1996 were analyzed. Three analyses of variance were performed, consisting of (1) no adjustment, (2) case mix (age, sex, race, and diabetes), and (3) case mix plus laboratory parameters. PD patients were younger (P < 0.001), a larger fraction were white (P < 0.001), fewer had diabetes (P < 0.001), and had lower serum albumin concentrations (P < 0.001) and higher creatinine, hemoglobin, and white blood cell count values (P < 0.001) than HD patients. Diabetes was present in a larger fraction of CCPD than CAPD patients (P < 0.001). HD and PD patients scored similarly for scales reflecting physical processes. PD patients scored higher for mental processes, but only after statistical adjustment for the laboratory measures. Scores on scales reflecting physical processes were worse, and those reflecting mental processes were better among CCPD than CAPD patients. HD and CAPD scores were similar. CCPD patients perceived themselves as more physically impaired but better adjusted than HD or CAPD patients. These descriptive data show that perception of QOL among PD and HD patients is similar before adjustment, but PD patients score higher for mental processes with adjustment. CCPD patients score worse for physical function and better for mental function than either CAPD or HD patients. We cannot, however, exclude the influence of therapy selection.

Effects of parathyroid hormone on renal function.

Parathyroid hormone has been recognized as an important factor in the regulation of renal function since the 1920s. Early investigations mainly characterized the role of the hormone in calcium and phosphorus metabolism. Subsequently, significant contributions have been made to the understanding of the influence of parathyroid hormone on acid-base balance and amino acid excretion. The following is a review of the effects of parathyroid hormone in the regulation of renal function with special emphasis on new developments.

Overlapping IgA and membranous nephropathy.

Four patients with overlapping IgA nephropathy and membranous nephropathy recently have been reported from two different medical centers in Japan. The authors describe two patients from the United States with the concurrence of IgA and membranous nephropathy and a third patient who may have the same overlapping glomerular lesions. All three patients had hematuria and nephrotic range proteinuria. Renal biopsy specimens from two of the patients revealed focal proliferative glomerular lesions, large mesangial and numerous subepithelial electron-dense deposits, exclusively mesangial intense immunostaining for IgA, and extensive granular capillary wall immunostaining for IgG. The third patient is a sibling of one of the other patients and was shown to have focal proliferative glomerular lesions, mesangial immunostaining for IgA, and numerous subepithelial electron-dense deposits. Pathogenic possibilities are discussed.

The treatment of anemia in peritoneal dialysis patients.

The management of anemia in patients with end-stage renal disease (ESRD) treated with peritoneal dialysis (PD) has gained increasing attention over the past decade, similar to patients on hemodialysis (HD). However, there are many differences between the 2 renal replacement therapies that pose unique challenges and solutions for monitoring, diagnosis and treatment of anemia in PD patients. These differences are not always evident and may be the result of different patient selection, physical, emotional and motivational factors, specific requirements of the modality or an indeterminate blend of infinite gradations of all these factors. This review will highlight current issues in anemia management in PD patients.

Complications of percutaneous renal biopsy: an analysis of 1,000 consecutive biopsies.

In a series of 1,000 consecutive percutaneous renal biopsies, adequate tissue for diagnosis was obtained in 94.9%. The rate of complications was 8.1% and was directly related to 1. age of the patient, 2. presence of renal insufficiency, and 3. arterial hypertension. The use of fluoroscopic control for localization of the kidney did not affect the rate of complications, nor did it improve the success rate in obtaining adequate tissue.

Fluoroscopic manipulation of Tenckhoff catheters: outcome analysis.

UNLABELLED: Wire manipulation under fluoroscopic control can correct malposition of peritoneal catheters in a fast and safe manner. This study was performed to evaluate the success rate of wire manipulation and identify factors that may predict outcome. MATERIAL AND METHODS: Data were prospectively collected between January 1, 1986 and June 30, 1996 among all patients with peritoneal catheter malfunction requiring manipulation at a single center. Manipulations were performed using a flexible guide wire under aseptic fluoroscopic control. All patients had flat plates of the abdomen pre and post manipulation and received antibiotics after the procedure. The direction of the subcutaneous tunnel at the point of entry into the peritoneal cavity was calculated from the X-rays by measuring the angle formed by the horizontal and the distal subcutaneous tunnel. Success was defined as adequate peritoneal catheter function at three months. The success rate was correlated with type of catheter, patient weight and the subcutaneous tunnel orientation. RESULTS: 1250 Tenckhoff double-cuff peritoneal catheters were inserted and 69 (5.5%) were manipulated (59 straight and 10 curled). The median for time elapsed between peritoneal catheter insertion and wire manipulation was 18 days (range 1 day-5 years). The overall success rate was 60.9% (61% for straight and 60% for curled peritoneal catheters). The mean patient weight for successes was 71.4 +/- 12.4 and 84.0 +/- 17.2 kg for failures (p < 0.005). Subcutaneous tunnel orientation between 30 and 120 degrees was associated with the highest success and those beyond 120 degrees with the highest failure rate. No complications were observed. CONCLUSIONS: Wire manipulation under fluoroscopic control of Tenckhoff peritoneal catheter in the treatment of malfunction is a safe and highly effective procedure. Obesity and cephalad orientation of the subcutaneous tunnel were associated with less favorable outcome.

Total parathyroidectomy and autotransplantation.

Total parathyroidectomy and autotransplantation of tissue to the forearm was practiced in 50 chronic renal failure patients as treatment for secondary hyperparathyroidism. Four hyperplastic glands were removed in all cases. Followup observation ranged from 3 to 42 months. Serum parathyroid hormone, alkaline phosphatase, calcium and phosphorus levels decreased significantly following the procedure (P less than 0.005) and remained stable during the period of observation. Significant bone pain present in 26 patients improved or ceased in 19; pruritus, present in 39 patients, universally improved. Strong radiographic suggestion of secondary hyperparathyroidism, present in 38 patients, improved or disappeared in 17. Three patients remained functionally hyperparathyroid, requiring further tissue removal. Autograft function 3 to 7 days after transplantation was demonstrated in 3 cases by differential parathyroid hormone concentration determinations. Essentially all patients experienced symptomatic improvement after surgery and most showed objective evidence of improved calcium-phosphorus metabolism and bone healing.

The influence of peritoneal dialysis on the outcome of transplantation.

The Authors' series of 44 patients transplanted after peritoneal dialysis suggests that the results of renal transplantation are comparable to those on hemodialysis.

Visual function in diabetic patients undergoing dialysis: comparison of peritoneal and hemodialysis.

A prospective, uncontrolled study was designed to evaluate the changes in visual efficiency among insulin-requiring diabetic patients undergoing peritoneal and hemodialysis. Of the 112 patients (63% adult onset and 37% juvenile onset diabetics) studied chronologically, 63% were treated with hemodialysis and 37% with peritoneal dialysis. The mean distribution of sex, age, observation period and initial visual function were the same in the peritoneal and hemodialysis subpopulations, but more juvenile onset diabetics were treated with peritoneal dialysis. Preservation of vision correlated well with overall blood pressure control in all dialysis groups. Loss of vision was independent of the dialysis modality, of glucose control, and of the type of onset of diabetes.

Management of peritonitis in automated peritoneal dialysis patients.

The management of peritonitis in patients undergoing automated peritoneal dialysis (APD) deserves special consideration due to the technical differences between APD modalities and continuous ambulatory peritoneal dialysis (CAPD). The use of very short exchanges may preclude the prompt diagnosis of peritonitis by diluting the peritoneal-cell population and causing spuriously low cell counts and clear effluent. Very long diurnal cycles can have the opposite result and give a falsely elevated cell count. The effluent from the multiple automated exchanges must be visually examined before being discarded in order to make a prompt diagnosis. Direct drainage of effluent into the sewage without inspection should be avoided. If direct drainage becomes a common practice, other alternatives such as on-line cell counters or chemical detectors of possible infection will be necessary. The recommendations for antimicrobial therapy developed for CAPD apply as well to APD. If single-day dosage is to be used, the longer exchanges of APD are ideal for intra-peritoneal delivery of antibiotics.

Optimizing diabetes management.

Diabetes mellitus is the fastest growing cause of end-stage renal disease and an important source of comorbidity among renal patients. A better understanding of diabetic pathophysiology has contributed to the development of effective prevention or treatment of many of its complications. The systematic application of several therapeutic recommendations based on clinical evidence can significantly reduce the rate of diabetic complications and improve the quality of life of the diabetic patient. Some of the most important recommendations are: (1) meticulous glycemic control to maintain HbA1c < or = 7.2%; (2) control of arterial blood pressure to normal levels (< 130/85 mmHg); (3) tobacco abstinence; (4) avoidance of excessive protein intake in the early stages of nephropathy; (5) aggressive nutritional monitoring and support; (6) early myocardial revascularization; (7) avoidance of unnecessary use of radiographic contrast media; and (8) appropriate initiation of dialysis with adequate delivered dose. Every effort should be made to provide effective education of the patient and health professionals. We must also develop regimens that interfere minimally with lifestyles in order to improve patient compliance with therapy.

The place for automated peritoneal dialysis.

The progress of automated peritoneal dialysis is initmately linked to the evolution of automated peritoneal delivery systems. The state of the art devices have incorporated computerized programs capable of delivering precise timing and volumes of dialysate and have made possible the delivery of CCPD, NPD, IPD or TPD with either time-controlled or volume-controlled delivery modes. Data storage and telephone transmission to the center have also helped in assessing compliance and documentation of dialysis delivered. The most common indications for automated peritoneal dialysis remain patient preference and the need for partner assistance. However, new indications have emerged from our better understanding of peritoneal dialysis kinetics and the recent emphasis on dialysis prescription and quality assurance.

Automated peritoneal dialysis therapies--patient selection and dialysis prescription.

The various modalities of automated peritoneal dialysis are discussed with emphasis on advantages and disadvantages, relative efficiency in states of normal and abnormal peritoneal permeability, and patient selection. The importance of residual renal function, peritoneal solute transport, body mass, protein intake and catabolic rate in formulating peritoneal dialysis prescription is reviewed.