Is the measurement of tissue advanced glycosylation products by skin autofluorescence associated with mortality in patients treated by peritoneal dialysis?

BACKGROUND: Advanced glycosylated end-products (AGEs) have been shown to cause cardiovascular disease, and tissue AGE accumulation can be measured by skin autofluorescence (SAF). AGEs are cleared by the kidney, and thus accumulate in dialysis patients. However, as the results of SAF measurements in peritoneal dialysis patients (PD) have been ambiguous, we examined the association between mortality and SAF. METHODS: We reviewed SAF measurements in PD patients attending a university associated PD program, along with standard measurements of dialysis adequacy and peritoneal membrane function. RESULTS: We studied 341 prevalent PD patients, 61.9% male, mean age 61.2 ± 16 years, and 31.4% of all patients died during a median follow-up of 27.2 (23.3-36.3) months. Patients who died were older, mean age 72 ± 10.5 years, were more often diabetic (60.7%), and had higher median SAF 3.8 (3.2-4.5) AU. On logistic regression, mortality was independently associated with age (odds ratio (OR) 1.1 (95% confidence limits 1.06-1.16), diabetes OR 10.1 (3.1-33.4), SAF OR 3.3 (1.8-6.2), all p < 0.001, and male gender OR 5.2 (1.6-17.4), p = 0.007; and negatively associated with weight OR 0.91 (0.86-0.95), p < 0..001, normalised nitrogen appearance rate (nPNA) OR 0.05 (0.01-0.4), p = 0.005 and mean arterial blood pressure (MAP) OR 0.96 (0.93-0.96), p = 0.03. CONCLUSIONS: In this observational study, SAF was independently associated with mortality. However, other factors were also associated with mortality, including age, diabetes and malnutrition which have all been reported to affect SAF measurements. Thus, the additional predictive value of measuring SAF compared to standard risk factors for mortality remains to be determined.

Bioimpedance spectroscopy: Is a picture worth a thousand words?

Volume status can be difficult to assess in dialysis patients. Peripheral edema, elevated venous pressure, lung crackles, and hypertension are taught as signs of fluid overload, but sensitivity and specificity are poor. Bioimpedance technology has evolved from early single frequency to multifrequency machines which apply spectroscopic analysis (BIS), modeling data to physics-based mixture theory. Bioimpedance plots can aid the evaluation of hydration status and body composition. The challenge remains how to use this information to manage dialysis populations, particularly as interventions to improve over hydration, sarcopenia, and adiposity are not without side effects. It is therefore of no surprise that validation studies for BIS use in peritoneal dialysis patients are limited, and results from clinical trials are inconsistent and conflicting. Despite these limitations, BIS has clinical utility with potential to accurately evaluate small changes in body tissue components. This article explains the information a BIS plot ("picture") can provide and how it can contribute to the overall clinical assessment of a patient. However, it remains the role of the clinician to integrate information and devise treatment strategies to optimize competing patient risks, fluid and nutrition status, effects of high glucose PD fluids on membrane function, and quality of life issues.

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment.

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

A case of paradoxical reaction after treatment of generalized tuberculous lymphadenopathy in a peritoneal dialysis patient.

Paradoxical reaction (also known as Jarisch-Herxheimer reaction) is a self-limited response to endotoxin released from dead bacteria after starting treatment and is characterized by constitutional symptoms such as fever, headache, dizziness and exacerbation of cutaneous lesions. We report a rare case of a 55-year-old gentleman, on peritoneal dialysis, who developed fever, dizziness and cloudy dialysate after starting anti-tuberculous treatment for disseminated tuberculous lymphadenitis. He was started on antibiotics for suspected peritoneal dialysis peritonitis and anti-tuberculosis treatment was continued. However, all his cultures turned out negative including peritoneal 16S ribosomal RNA. The diagnosis of paradoxical worsening following anti-tuberculosis treatment was made. His peritoneal dialysis was continued and he made full recovery after 8 months of therapy. This case highlights the fact that in a peritoneal dialysis patient, paradoxical reaction can present as cloudy dialysate with raised infective markers.

Persistent colonization of exit site is associated with modality failure in peritoneal dialysis.

Exit-site infections (ESIs) increase the risk of developing peritoneal dialysis (PD) peritonitis and PD technique failure. There are no clear guidelines on how to monitor exit site (ES) after ESI with Staphylococcus aureus or Pseudomonas. We report on a 1-year observational study of 23 patients who developed an ESI with one of these serious pathogens. After completing initial antibiotic treatment, swabs were taken every month for 3 months. Primary treatment cure occurred in 19/23 (83%). Colonization of ES after primary cure occurred in 8/19 (42%) patients. In the eight colonized patients, five had subsequent PD technique failure due to infections. By contrast, during an average follow-up period of 7.2 months, none of the 11 patients who were proven noncolonized developed PD technique failure from infections; HR (colonized vs. noncolonized) = 10.89, 95% CI 2.6-45.43, p < 0.05. In conclusion, colonization significantly increased the risk of catheter loss. Increased surveillance and aggressive treatment may ameliorate this risk.

Overcoming barriers and building a strong peritoneal dialysis programme - Experience from three South Asian countries.

The development of peritoneal dialysis (PD) programmes in lower-resource countries is challenging. This article describes the learning points of establishing PD programmes in three countries in South Asia (Nepal, Sri Lanka and Pakistan). The key barriers identified were government support (financial), maintaining stable supply of PD fluids, lack of nephrologist and nurse expertise, nephrology community bias against PD, lack of nephrology trainee awareness and exposure to this modality. To overcome these barriers, a well-trained PD lead nephrologist (PD champion) is needed, who can advocate for this modality at government, professional and community levels. Ongoing educational programmes for doctors, nurses and patients are needed to sustain the PD programmes. Support from well-established PD centres and international organisations (International Society of Peritoneal Dialysis (ISPD), International Society of Nephrology (ISN), International Pediatric Nephrology Association (IPNA) are essential.

Tackling Dialysis Burden around the World: A Global Challenge.

CKD is a global problem that causes significant burden to the healthcare system and the economy in addition to its impact on morbidity and mortality of patients. Around the world, in both developing and developed economies, the nephrologists and governments face the challenges of the need to provide a quality and cost-effective kidney replacement therapy for CKD patients when their kidneys fail. In December 2019, the 3rd International Congress of Chinese Nephrologists was held in Nanjing, China, and in the meeting, a symposium and roundtable discussion on how to deal with this CKD burden was held with opinion leaders from countries and regions around the world, including Australia, Canada, China, Hong Kong, Singapore, Taiwan, the UK, and the USA. The participants concluded that an integrated approach with early detection of CKD, prompt treatment to slow down progression, promotion of home-based dialysis therapy like peritoneal dialysis and home HD, together with promotion of kidney transplantation, are possible effective ways to combat this ongoing worldwide challenge.

Relationship between sodium removal, hydration and outcomes in peritoneal dialysis patients.

BACKGROUND: Fluid overload (FO) in peritoneal dialysis (PD) patients is associated with mortality. We explore if low daily sodium removal is an independent risk factor for mortality. We examined severely FO PD patients established for >1 year in expectation that PD prescription would have been optimized for solute clearance and ultrafiltration. We also wish to determine the relationship between kt/v and sodium removal. METHODS: Retrospective analysis of 231 PD patients with FO ≥2.0 L and compared with 218 PD patients who were euvolaemic throughout their PD treatment. Patients were followed up until death censored for transplantation. RESULTS: Mean daily sodium removal in overhydrated patients was only 75 mmoles (=1.7 g). CAPD usage was more common in patients with the highest sodium removal. Achievement of UK guidelines for solute clearance and daily fluid removal were not independent predictors of mortality. Markers of sarcopenia (low serum albumin and high CRP) were associated with increased mortality, but these parameters were not independent predictors in a model that included functional assessment (Karnofsky score). Daily sodium removal was not predictive of mortality but the imprecision of clinically used sodium assay should be noted. The correlation between Na and kt/v is statistically significant but R2 was weak at .07. CONCLUSION: While diabetic males were more likely to become overhydrated, these factors did not increase mortality further. Traditional targets of 'dialysis adequacy' did not predict survival. Kt/v is not a good indicator of sodium removal which can be surprisingly low. Measuring sodium clearance may help clinicians optimize PD modality (CAPD vs. APD).

The impact of volume overload on technique failure in incident peritoneal dialysis patients.

BACKGROUND: Technique failure in peritoneal dialysis (PD) can be due to patient- and procedure-related factors. With this analysis, we investigated the association of volume overload at the start and during the early phase of PD and technique failure. METHODS: In this observational, international cohort study with longitudinal follow-up of incident PD patients, technique failure was defined as either transfer to haemodialysis or death, and transplantation was considered as a competing risk. We explored parameters at baseline or within the first 6 months and the association with technique failure between 6 and 18 months, using a competing risk model. RESULTS: Out of 1092 patients of the complete cohort, 719 met specific inclusion and exclusion criteria for this analysis. Being volume overloaded, either at baseline or Month 6, or at both time points, was associated with an increased risk of technique failure compared with the patient group that was euvolaemic at both time points. Undergoing treatment at a centre with a high proportion of PD patients was associated with a lower risk of technique failure. CONCLUSIONS: Volume overload at start of PD and/or at 6 months was associated with a higher risk of technique failure in the subsequent year. The risk was modified by centre characteristics, which varied among regions.

Polymerase chain reaction/electrospray ionization-mass spectrometry (PCR/ESI-MS) is not suitable for rapid bacterial identification in peritoneal dialysis effluent.

BACKGROUND: Peritoneal dialysis (PD)-related peritonitis is a serious complication of PD, but routine microbiological culture is slow and could not identify the organism in 15% cases. We examine the accuracy of polymerase chain reaction/electrospray ionization-mass spectrometry (PCR/ESI-MS), a PCR-based method developed for the direct detection of bacteria in blood, for rapid identification of microorganisms from PD effluent. METHODS: We recruited 73 consecutive patients with PD-related peritonitis. Dialysis effluent was collected for routine bacterial culture, PCR/ESI-MS, and bacterial DNA quantification before initiation of antibiotic therapy. RESULTS: By digital PCR with universal bacterial primers, bacterial DNA was detectable in all PD effluent specimens. For the entire cohort, taking standard bacterial culture as the gold standard, the PCR/ESI-MS assay correctly identified 34.3% of the causative organisms, failed to identify any organism in 52.1% cases, and identified a different organism in 8.2% cases. For the 14 episodes of peritonitis that were culture negative by conventional bacterial culture, the PCR/ESI-MS assay identified an organism in only four cases. The detection rate of the IRIDICA BAC BSI assay was not affected by the use of biocompatible PD solution or concomitant exit-site infection. CONCLUSIONS: The PCR/ESI-MS assay could not identify the causative organism in over 50% of the PD effluent samples in patients with PD-related peritonitis and should be not used for such purpose. The reason for the poor performance needs further investigation.

Comparison between standard single chamber versus dual chamber low glucose degradation product peritoneal dialysis fluids.

Dual chamber (DC) peritoneal dialysis (PD) dialysates contain fewer glucose degradation products (GDPs), so potentially reducing advanced glycosylation end products (AGEs), which have been reported to increase inflammation and cardiovascular risk. We wished to determine whether use of DC dialysates resulted in demonstrable patient benefits. Biochemical profiles, body composition, muscle strength, and skin autofluorescence measurements of tissue AGEs (SAF) were compared in patients using DC and standard single chamber dialysates. We studied 263 prevalent PD patients from 2 units, 62.4% male, mean age 61.8 ± 16.1 years, 78 (29.7%) used DC dialysates. DC patients were younger (55.9 ± 16.4 vs. 64.2 ± 15.4 years), and more had lower Davies comorbidity score (median 1 (0-1) vs. 1 (0, 2)), slower peritoneal transport (D/P creatinine 0.67 ± 0.12 vs. 0.73 ± 0.13), greater extracellular water-to-total body water (ECW/TBW) ratio (0.46 ± 0.05 vs. 0.42 ± 0.06), all P < .001, whereas there were no differences in the duration of PD (median (IQR) 19 (8-32) vs. 14 (8-23) months), residual renal function (Kt/Vurea 0.71 ± 0.71 vs. 0.87 ± 0.82), urine volume (642 (175-1200) vs. 648 (300-1200) mL/day), hand grip strength (26.9 ± 10.5 vs. 24.9 ± 10.7 kg), C-reactive protein (4(1-10) vs. 4(2-12) mg/L), and SAF (median 3.60 (3.02, 4.40) vs. 3.50 (3.00, 4.23)) AU. In our cross-sectional observational study, we were not able to show a demonstrable advantage for using low GDP dialysates over conventional glucose dialysates, in terms of biochemical profiles, residual renal function, muscle strength, or tissue AGE deposition. More patients using low GDP dialysates were slower peritoneal transporters with higher ECW/TBW ratios.

HEROIC: a 5-year observational cohort study aimed at identifying novel factors that drive diabetic kidney disease: rationale and study protocol.

INTRODUCTION: Diabetic kidney disease (DKD) is the leading cause of end-stage kidney disease worldwide and a major cause of premature mortality in diabetes mellitus (DM). While improvements in care have reduced the incidence of kidney disease among those with DM, the increasing prevalence of DM means that the number of patients worldwide with DKD is increasing. Improved understanding of the biology of DKD and identification of novel therapeutic targets may lead to new treatments. A major challenge to progress has been the heterogeneity of the DKD phenotype and renal progression. To investigate the heterogeneity of DKD we have set up The East and North London Diabetes Cohort (HEROIC) Study, a secondary care-based, multiethnic observational study of patients with biopsy-proven DKD. Our primary objective is to identify histological features of DKD associated with kidney endpoints in a cohort of patients diagnosed with type 1 and type 2 DM, proteinuria and kidney impairment. METHODS AND ANALYSIS: HEROIC is a longitudinal observational study that aims to recruit 500 patients with DKD at high-risk of renal and cardiovascular events. Demographic, clinical and laboratory data will be collected and assessed annually for 5 years. Renal biopsy tissue will be collected and archived at recruitment. Blood and urine samples will be collected at baseline and during annual follow-up visits. Measured glomerular filtration rate (GFR), echocardiography, retinal optical coherence tomography angiography and kidney and cardiac MRI will be performed at baseline and twice more during follow-up. The study is 90% powered to detect an association between key histological and imaging parameters and a composite of death, renal replacement therapy or a 30% decline in estimated GFR. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Bloomsbury Research Ethics Committee (REC 18-LO-1921). Any patient identifiable data will be stored on a password-protected National Health Services N3 network with full audit trail. Anonymised imaging data will be stored in a ISO27001-certificated data warehouse.Results will be reported through peer-reviewed manuscripts and conferences and disseminated to participants, patients and the public using web-based and social media engagement tools as well as through public events.

Single-dwell treatment with a low-sodium solution in hypertensive peritoneal dialysis patients.

BACKGROUND: Patients on peritoneal dialysis (PD) may suffer from sodium (Na) and fluid overload, hypertension and increased cardiovascular risk. Low-Na dialysis solution, by increasing the diffusive removal of Na, might improve blood pressure (BP) management. METHODS: A glucose-compensated, low-Na PD solution (112 mmol/L Na and 2% glucose) was compared to a standard-Na solution (133 mmol/L Na and 1.5% glucose) in a prospective, randomised, single-blind study in hypertensive patients on PD. One daily exchange of the standard dialysis regimen was substituted by either of the study solutions for 6 months. The primary outcome (response) was defined as either a decrease of 24-h systolic BP (SBP) by ≥6 mmHg or a fall in BP requiring a medical intervention (e.g. a reduction of antihypertensive medication) at 8 weeks. RESULTS: One hundred twenty-three patients were assessed for efficacy. Response criteria were achieved in 34.5% and 29.1% of patients using low- and standard-Na solutions, respectively (p = 0.51). Small reductions in 24 h, office, and self-measured BP were observed, more marked with low-Na than with standard-Na solution, but only the between-group difference for self-measured SBP and diastolic BP was significant (p = 0.002 and p = 0.003). Total body water decreased in the low-Na group and increased in the control group, but between-group differences were not significant. Hypotension and dizziness occurred in 27.0% and in 11.1% of patients in the low-Na group and in 16.9% and 4.6% in the control group, respectively. CONCLUSIONS: Superiority of low-Na PD solution over standard-Na solution for control of BP could not be shown. The once daily use of a low-Na PD solution was associated with more hypotensive episodes, suggesting the need to reassess the overall concept of how Na-reduced solutions might be incorporated within the treatment schedule.

Quality of life with conservative care compared with assisted peritoneal dialysis and haemodialysis.

BACKGROUND: There is little information about quality of life (QoL) for patients with end-stage kidney disease (ESKD) choosing conservative kidney management (CKM). The Frail and Elderly Patients on Dialysis (FEPOD) study demonstrated that frailty was associated with poorer QoL outcomes with little difference between dialysis modalities [assisted peritoneal dialysis (aPD) or haemodialysis (HD)]. We therefore extended the FEPOD study to include CKM patients with estimated glomerular filtration rate ≤10 mL/min/1.73 m2 (i.e. individuals with ESKD otherwise likely to be managed with dialysis). METHODS: CKM patients were propensity matched to HD and aPD patients by age, gender, ethnicity, diabetes status and index of deprivation. QoL outcomes measured were Short Form-12 (SF12), Hospital Anxiety and Depression Scale depression score, symptom score, Illness Intrusiveness Rating Scale (IIRS) and Renal Treatment Satisfaction Questionnaire. Frailty was assessed using the Clinical Frailty Scale. Generalized linear modelling was used to assess the impact of treatment modality on QoL outcomes, adjusting for baseline characteristics. RESULTS: In total, 84 (28 CKM, 28 HD and 28 PD) patients were included. Median age for the cohort was 82 (79-88) years. Compared with CKM, aPD was associated with higher SF12 physical component score (PCS) [Exp B (95% confidence interval) = 1.20 (1.00-1.45), P < 0.05] and lower symptom score [Exp B = 0.62 (0.43-0.90), P = 0.01]; depression score was lower in HD compared with CKM [Exp B = 0.70 (0.52-0.92), P = 0.01]. Worsening frailty was associated with higher depression scores [Exp B = 2.59 (1.45-4.62), P < 0.01], IIRS [Exp B = 1.20 (1.12-1.28), P < 0.01] and lower SF12 PCS [Exp B = 0.87 (0.83-0.93), P < 0.01]. CONCLUSION: Treatment by dialysis, both with aPD and HD, improved some QoL measures. Overall, aPD was equal to or slightly better than the other modalities in this elderly population. However, as in the primary FEPOD study, frailty was associated with worse QoL measures irrespective of CKD modality. These findings highlight the need for an individualized approach to the management of ESKD in older people.

Performance of Gram Stains and 3 Culture Methods in the Analysis of Peritoneal Dialysis Fluid.

Microbiological diagnosis of peritoneal dialysis (PD)-related peritonitis includes PD fluid cell count, Gram stain, and culture, as recommended by the International Society for Peritoneal Dialysis. In this retrospective study, we examined the utility of Gram stains and compared 3 culture methods.We examined a laboratory cohort (samples sent to the laboratory for any reason; n = 251) and a clinical cohort (samples sent from patients felt clinically to have peritonitis; n = 264). Culture positivity rates were higher in the clinical cohort (39.4%) than the laboratory cohort (21.5%), with no difference in the distribution of organisms between the cohorts; cell counts were significantly higher in culture-positive samples in both cohorts.Rates of positivity in the laboratory and clinical cohorts, respectively, were as follows: Gram stains 1.9% and 7.7%; direct plate culture 13% and 30.8% and "bedside" inoculated blood culture bottles 82.1% and 92.8%. Enrichment culture was never negative when another method was positive.Our data indicate that enrichment culture can be used as a single culture methodology for analyzing PD fluid without loss of sensitivity. They also suggest that Gram stains are of relatively low yield; consideration could be given to ceasing their routine performance provided that broad antimicrobial therapy is administered pending culture results.

Clinical Value of Screening Peritoneal Dialysis Patients for Bacterial Colonization or Contamination.

INTRODUCTION: The adoption of the International Society for Peritoneal Dialysis guideline of using mupirocin ointment has been limited by fear of developing mupirocin-resistant organisms. We performed a surveillance program of a large peritoneal dialysis (PD) unit. METHODS: We performed 1,175 surveillance swabs from anterior nares, PD catheter exit site, groin, and axilla, from 240 patients. The mean interval between swabs was 3.3 months. RESULTS: Colonization by Staphylococcus aureus (S. aureus) or Pseudomonas species was 9.5% and 10.9%, respectively. Despite adopting a universal policy of applying mupirocin to PD catheter exit sites in 2001, no instances of mupirocin-resistant S. aureus were identified. Moreover, patients who grew S. aureus from surveillance swabs did not experience higher peritonitis rates than those with "no growth." This was in contrast to patients who grew Pseudomonas or enteric organisms. There were no differences in patient demographics for those who grew S. aureus, Pseudomonas, or enteric organisms (compared with "no-growth" patients). CONCLUSION: Our results suggest that the application of mupirocin ointment appeared to minimize peritonitis of patients colonized with S. aureus. The use of mupirocin in this patient cohort has not led to mupirocin resistance. The increased peritonitis rate of patients who grew Pseudomonas or enteric organisms is of interest. We propose that greater attention to hygiene and catheter care in these patients is warranted. The increasing use of paid healthcare workers attending patients daily to help perform PD (assisted PD) gives an opportunity for us to address these wider issues.

Clinical value of body composition monitor to evaluate lean and fat tissue mass in peritoneal dialysis.

BACKGROUND/OBJECTIVES: Bioimpedance analysis is often routinely performed in any dialysis unit to guide fluid management but can provide a reproduceable assessment of fat and muscle mass. We wished to determine the clinical significance of low muscle or high fat mass and the determinants that influence their change. SUBJECTS/METHODS: We performed retrospective analysis of 824 patients on peritoneal dialysis who underwent routine repeated bioimpedance analysis measurements using the body composition monitor (BCM). RESULTS: Lean tissue index (LTI) was an independent predictor of mortality when sex, age, PD vintage and diabetes status were included in the models (HR 0.93; 95% CI 0.86-1.00, p < 0.05) and when baseline serum albumin was included in a separate model (HR 0.86; 95% CI: 0.79-0.93, p < 0.001). High fat tissue index (FTI) was an independent predictor of mortality when demographic factors were included (HR 0.87; 95% CI: 0.78-0.97, p < 0.02), but not with the addition biochemical parameters. Changes in body composition of 206 patients over a 2-year follow-up period could not be predicted by baseline demographics, functional or biochemical assessments. However, there was a strong inverse relationship between changes in LTI and FTI. There were no associations between changes in body composition with prescribed dialysate glucose. CONCLUSIONS: We showed body composition changes are common and complex. LTI was an independent predictor of survival. Changes in LTI and FTI could not be predicted by baseline parameters. BCM may be a sensitive and accurate tool to monitor changes in body composition during dialysis treatment.

Comparison of skin autofluorescence, a marker of tissue advanced glycation end-products in peritoneal dialysis patients using standard and biocompatible glucose containing peritoneal dialysates.

BACKGROUND: Heat sterilization of peritoneal dialysis (PD) dialysates leads to the generation of advanced glycation products (AGE), which can then deposit in the skin and be measured by skin autofluorescence (SAF). Newer biocompatible dual chamber dialysates contain less AGE. We wished to determine whether the use of these newer dialysates resulted in lower SAF. METHODS: Skin autofluorescence was measured using the AGE reader, which directs ultraviolet light, intensity range 300-420 nm (peak 370 nm) in patients established on PD for >3 months using glucose containing dialysates. RESULTS: We screened 196 consecutive patients, and measured SAF in 150; 86 (57.3%) male, median age 62 (53-71) years, median duration of PD treatment 17 (8.6-34.3) months. The median SAF was 3.48 (2.92-4.26) AU. The median SAF in the 57 (38%) patients prescribed biocompatible dual chamber bag dialysates was 3.39 (2.69-3.98) versus 3.5 (3.05-4.54) for those using standard dialysates (P = 0.044). Although prescription of biocompatible fluids was associated with SAF on univariate analysis, but not on multivariable testing, SAF was independently associated with Stoke-Davies co-morbidity grade (ß 0.045, 95% confidence limits (CL) 0.015-0.075, P = 0.002), log duration of PD therapy (ß 0.051, CL 0.001-0.101, P = 0.045), white ethnicity (ß 0.066, CL 0.028-0.104, P = 0.001), and negatively with serum albumin (ß -0.006, CL -0.008 to -0.004, P = 0.014). CONCLUSION: Although SAF was lower in PD patients prescribed biocompatible dual chamber dialysates, on multivariable testing these dialysates were not independently associated with SAF. Other factors than PD fluid AGE content appear more important in determining SAF.

Peritoneal dialysis in patients with failed kidney transplant: Single centre experience.

AIM: To determine if patients with failing kidney transplants who opt to have peritoneal dialysis (PD) have poor short-term PD technique survival and increased rates of peritonitis. METHODS: We performed a retrospective analysis comparing 50 consecutive patients starting PD after a failed kidney transplant to 93 incident patients starting PD (matching for age, gender, diabetes causing renal failure, ethnicity and year of starting PD). RESULTS: The mean follow-up period was 26 months. PD technique survival was lower for the post-transplant cohort. However, this did not appear to be related to PD peritonitis risk; infection rate was lower in the post-transplant group albeit not statistically significant (1 in 23.6 patient months vs 1 in 22.5 patient months). There were no differences in the proportion of Gram positive: Gran negative: Culture Negative infections. The only fungal peritonitis occurred in a Control patient. Results of baseline Peritoneal Equilibration Tests were not different; D/Pcr was 0.69 for post-TP versus 0.64 for Control (P = ns), and net UF was 250 mL for post-TP versus 310 mL for Control (P = ns). PET results after 12 months were also similar. CONCLUSION: Our study found a small but significantly higher rate of PD technique failure in the post-transplant cohort, but this did not appear to be related to peritonitis rates or peritoneal membrane function. Further studies are required to explore reasons for PD technique failure in patients who have had kidney transplant, but our study supports the use of PD in selected patient from this cohort.