The impact of continuous renal replacement therapy on renal outcomes in dialysis-requiring acute kidney injury may be related to the baseline kidney function.

BACKGROUND: Many controversies exist regarding the management of dialysis-requiring acute kidney injury (D-AKI). No clear evidence has shown that the choice of dialysis modality can change the survival rate or kidney function recovery of critically ill patients with D-AKI. METHODS: We conducted a retrospective study investigating patients (≥16 years old) admitted to an intensive care unit with D-AKI from 1999 to 2012. We analyzed D-AKI incidence, and outcomes, as well as the most commonly used dialysis modality over time. Outcomes were based on hospital mortality, renal function recovery (estimated glomerular filtration rate-eGFR), and the need for dialysis treatment at hospital discharge. RESULTS: In 1,493 patients with D-AKI, sepsis was the main cause of kidney injury (56.2%). The comparison between the three study periods, (1999-2003, 2004-2008, and 2009-2012) showed an increased in incidence of D-AKI (from 2.56 to 5.17%; p = 0.001), in the APACHE II score (from 20 to 26; p < 0.001), and in the use of continuous renal replacement therapy (CRRT) as initial dialysis modality choice (from 64.2 to 72.2%; p < 0.001). The mortality rate (53.9%) and dialysis dependence at hospital discharge (12.3%) remained unchanged over time. Individuals who recovered renal function (33.8%) showed that those who had initially undergone CRRT had a higher eGFR than those in the intermittent hemodialysis group (54.0 × 46.0 ml/min/1.73 m2, respectively; p = 0.014). In multivariate analysis, type of patient, sepsis-associated AKI and APACHE II score were associated to death. For each additional unit of the APACHE II score, the odds of death increased by 52%. The odds ratio of death for medical patients with sepsis-associated AKI was estimated to be 2.93 (1.81-4.75; p < 0.001). CONCLUSION: Our study showed that the incidence of D-AKI increased with illness severity, and the use of CRRT also increased over time. The improvement in renal outcomes observed in the CRRT group may be related to the better baseline kidney function, especially in the dialysis dependence patients at hospital discharge.

Patient and technique survival in continuous ambulatory peritoneal dialysis in a single center of the west of Mexico.

INTRODUCTION: In Mexico, CAPD survival has been analyzed in few studies from the center of the country. However, there are concerns that such results may not represent what occurs in other province centers of our country, particularly in our geographical area. AIM: To evaluate the patient and technique survival on CAPD of a single center of the west of Mexico, and compare them with other reported series. DESIGN: Retrospective cohort study. SETTING: Tertiary care, teaching hospital located in Guadalajara, Jalisco. PATIENTS: Patients from our CAPD program (1999-2002) were retrospectively studied. Interventions. Clinical and biochemical variables at the start of dialysis and at the end of the follow-up were recorded and considered in the analysis of risk factors. MAIN OUTCOME MEASURES: Endpoints were patient (alive, dead or lost to follow-up) and technique status at the end of the study (June 2002). RESULTS: 49 patients were included. Mean patient survival (+/- SE) was 3.32 +/- 0.22 years (CI 95%: 2.9-3.8 years). Patients in the present study were younger (39 +/- 17yrs), had larger body surface area (1.72 +/- 0.22 m2), lower hematocrit (25.4 +/- 5.2%), albumin (2.6 +/- 0.6g/dL), and cholesterol (173 +/- 44 mg/dL), and higher urea (300 +/- 93 mg/dL) and creatinine (14.9 +/- 5.6 mg/ dL) than those in other Mexican series. In univariate analysis, the following variables were associated (p < 0.05) to mortality: pre-dialysis age and creatinine clearance, and serum albumin and cholesterol at the end of follow-up. In multivariate analysis, only pre-dialysis creatinine clearance (RR 0.66, p = 0.03) and age (RR 1.08, p = 0.005) significantly predicted mortality. Mean technique survival was 2.83 +/- 0.24 years (CI 95%: 2.4-3.3). Pre-dialysis age (p < 0.05), peritonitis rate (p < 0.05), and serum phosphorus at the end of follow-up (p < 0.05) were associated with technique failure in univariate analysis, while in multivariate analysis, only pre-dialysis age (RR 1.07, p = 0.001) and peritonitis rate (RR 481, p < 0.0001) were technique failure predictors. CONCLUSIONS: Patients from this single center of the west of Mexico were younger, had higher body surface area and initiated peritoneal dialysis with a more deteriorated general status than patients reported in other Mexican series; in spite of the latter, patient and technique survival were not different. In our setting, pre-dialysis older age and lower CrCl significantly predicted mortality, while older predialysis age and higher peritonitis rate predicted technique failure.

Risk of peritonitis among disadvantaged CAPD patients in Mexico.

BACKGROUND/AIMS: Continuous ambulatory peritoneal dialysis is the first-choice treatment for ESRD in Mexico. Peritonitis is the most frequent cause of morbidity and is among the leading causes of technique failure in our country. Our objective was to compare the efficacy of the standard and double-bag disconnect systems for the prevention of peritonitis in a high-risk population with poor living standards, and high prevalence of malnutrition and diabetes rates. METHODS: Episodes of peritonitis registered between July 1989 and June 2003 were included. Patients were divided in conventional and double-bag groups. Between July 1989 and May 1999, all patients used the conventional system. From May 1999, all incident patients were placed on a double-bag disconnect system. RESULTS: Six-hundred and forty-seven patients started dialysis in the study period, 383 in the conventional group, and 264 in the double-bag. The peritonitis rate observed was 1 episode per 7.2 patient-months in the conventional group, and 1 episode per 25.1 patient-months in the double-bag system (p < 0.001). Cumulative peritonitis-free survival rate at 6 (50 vs. 82%), 12 (27 vs. 69%) and 24 (12 vs. 45%) months, respectively, was significantly lower in the conventional group (p < 0.001). Technique survival at 1 (75 vs. 85%), 2 (68 vs. 80%), and 3 years (50 vs. 80%), was worse in the conventional group (p < 0.001). By multivariate analysis, the only factor associated with peritonitis was the connecting system. CONCLUSIONS: We conclude that switching from a standard to a double-bag system using electrolytically produced sodium hypochlorite disinfectant markedly decreased the peritonitis rate, even in a high-risk population like ours.

Renal replacement therapy among disadvantaged populations in Mexico: a report from the Jalisco Dialysis and Transplant Registry (REDTJAL).

BACKGROUND: End-stage renal disease represents a serious public health problem in Jalisco, Mexico. It is reported among the 10 leading causes of death, with an annual mortality rate of 12 deaths per 100,000 population. The state population is 6.3 million, and more than half do not have medical insurance. In this study, we report the population's access to renal replacement therapy (RRT). METHODS: Patients > or =15 years of age, who started RRT between January 1998 and December 2000 at social security or health secretariat medical facilities, were included. Nine facilities participated in the study. At the start of treatment, the patient's facility, age, gender, cause of renal failure, and initial treatment modality were registered. RESULTS: Within the study period, 2456 started RRT, 1767 (72%) at social security facilities and 687 (28%) at health secretariat facilities, for an annual incidence rate of 195 per million population (pmp). The main cause of renal failure was diabetes mellitus (51% of patients). There were significant differences between the 2 populations. Patients with social security were older (53.1 +/- 17 vs. 45.1 +/- 20 years, P= 0.001) and had more diabetes (54% vs. 42%, P= 0.001) than those without social security. They had higher acceptance (327 pmp vs. 99 pmp, P= 0.001) and prevalence rates (939 pmp vs. 166 pmp, P= 0.001) than patients without medical insurance. Dialysis use was similar in both populations. Eighty-five percent of patients were on continuous ambulatory peritoneal dialysis and 15% on hemodialysis. Kidney transplant rate was higher among insured patients (72 pmp vs. 7.5 pmp, P= 0.001). The number of dialysis programs and nephrologists that offered renal care also differed. There were 10 dialysis programs in social security and 3 in health secretariat facilities. Fourteen nephrologists looked after the insured population, whereas 5 cared for the uninsured (7.7 pmp vs. 2.1 pmp, P= 0.001). The latter had access to 8 hemodialysis stations compared with 34 for the insured population (3.4 pmp vs. 18.8 pmp, P= 0.001). CONCLUSIONS: Access to RRT is unequal in our state. Although it is universal for the insured population, it is severely restricted for the poor. Social and economical factors, as well as the limited number of understaffed, centralized dialysis facilities, could explain these differences.

Peritoneal dialysis in Mexico.

While Mexico has the thirteenth largest economy, a large portion of the population is impoverished. About 90% of the population is Mestizo, the result of the admixture of Mexican Indians and Spaniards, with the Indigenous peoples concentrated in the southeastern region. Treatment for end-stage renal disease (estimated 268 patients per million population) is largely determined by the limited healthcare system and the individual's access to resources such as private insurance ( approximately 15%) and governmental sources ( approximately 85%). With only 5% of the gross national product spent on healthcare and most treatment providers being public health institutions that are often under severe economic restrictions, it is not surprising that many Mexican patients do not receive renal replacement therapy. Mexico uses proportionately more peritoneal dialysis than other countries; 1% of the patients are on automated peritoneal dialysis, 19% on hemodialysis and 80% on CAPD. Malnutrition and diabetes, important risk factors for poor outcome, are prevalent among the patients in CAPD programs.

[Factors associated with peritoneal dialysis catheter failure in chronic renal insufficiency]. / Factores asociados a falla del catéter de diálisis peritoneal en insuficiencia renal crónica.

AIM: To determine the frequency, time of occurrence and factors associated with the failure of the permanent peritoneal catheter during dialysis in cases of chronic renal failure (CRF). MATERIAL AND METHODS: A retrospective cohort under a nested case control design was studied at a second level health care unit of the Instituto Mexicano del Seguro Social. A total of 149 catheters, double cushion straight Tenckhoff type, were evaluated in 74 patients with CRF due to diabetic nephropathy in 36/74 patients (49%). Information concerning functionality time and causes of catheter failure as well as the clinical and technical factors concerning insertion were obtained from the clinical chart. RESULTS: The cumulated time of dialysis was 814 months. Catheter failure occurred in 101 cases (68%): 67 due to obstruction, 24 due to infection, to leakage in 6 and to other causes in 4. Those of non-infectious origin were more frequent (p < 0.01). In the first month post-insertion there was a higher number of failures than after one month, (p < 0.0005). The global functionality of the catheter at one month, one and two years was 55%, 31% and 16%, respectively. There was a greater permanence of the catheters in continuous ambulatory peritoneal dialysis than in intermittent peritoneal dialysis (p = 0.02). CONCLUSIONS: It is concluded that the frequency of the peritoneal catheter failure was high; that the most frequent cause was due to non-infectious complications during the first month of insertion; and the factor associated to catheter failure was intermittent peritoneal dialysis as compared to continuous ambulatory dialysis.

Complicaciones de la diálisis peritoneal continua ambulatoria en niños con insuficiencia renal crónica / Complications of ambulatory continuous peritoneal dialysis in children with chronic renal failure

Introducción. La diálisis peritoneal continua ambulatoria (DPCA) constituye actualmente el tratamiento sustituto más utilizado en pediatría en pacientes con insuficiencia renal crónica terminal (IRCT) antes de recibir un trasplante renal. Material y métodos. Se revisaron los expedientes clíncos de 56 niños con IRCT en programa de DPCA en el Hospital Infantil de México Federico Gómez durante el período 1991-1995, que tuvieron un tiempo mínimo de diálisis de 3 meses, con el fin de determinar la frecuencia y características de las complicaciones del procedimiento. Resultados. Se instalaron 96 catéteres de Tenckhoff en los 56 pacientes; se utilizó el método estándar de DPCA, con un tiempo promedio del procedimiento de 19.4ñ13 meses. Se observaron 42 complicaciones relacionadas al catéter (infección del túnel y sitio de salida y disfunción principalmente) con una frecuencia de una complicación cada 25.6 meses de diálisis. Asimismo se presentaron 109 complicaciones clínicas, pricipalmente peritonitis: 104 episodios con frecuencia de un episodio cada 10.3 meses (1.16 episodios por paciente por año). Al terminar el estudio, 27 pacientes continuaban en programa de DPCA y en 29 se había suspendido el procedimiento: en 25 por transplante renal, en 2 por transferencia de hemodiálisis y 2 por razones socioeconómicas. Ningún paciente falleció durante el período de estudio. Conclusiones. A pesar de que los niños en programa de DPCA presentan un índice alto de complicaciones atribuidas al catéter instalado y al procedimiento en sí, sólo en un número reducido de casos se observa el fracaso del método de diálisis. Por otro lado, la introducción de los nuevos métodos de conexión-desconexión pueden permitir reducir aún más la frecuencia de las complicaciones, principalmente de tipo infeccioso

CAPD in southern Brazil: an epidemiological study.

There are many studies on the performance of continuous ambulatory peritoneal dialysis (CAPD) in developed countries, but studies in the third world are scarce. The aim of this study is to analyze CAPD experience in the southernmost state of Brazil (Rio Grande do Sul, RS). Records were obtained from the Health Secretary of RS to assemble a cohort of all patients treated with CAPD. Another cohort study followed all patients initiating treatment for uremia in 1993 in the state capital, Porto Alegre, and compared CAPD, hemodialysis, and transplanted patients. In RS, 1316 patients (50.4% male, mean age 45.9 years) were treated in 40 CAPD programs. Despite the initial growth of the CAPD population, it subsequently leveled off. Survival was 78.6% and 40.7% in years 1 and 5, being worse for initial patients of each program, infants, and elders. Technique survival was 57.4% and 10.1% at years 1 and 5. Patients interrupting treatment for any reason had a higher chance of dropout. In Porto Alegre, 294 patients started dialysis during 1993; 21 performed CAPD, 44 had a transplant, and the others were hemodialyzed. Children were treated mostly by CAPD. CAPD patients had less diabetes and ischemic heart disease and received more transplants. Their adjusted actuarial survival (100% year 1; 67% year 3) was no different than hemodialysis. CAPD is not a popular form of renal therapy in RS, and dropout rates are significant.

Epidemiologic and demographic aspects of peritoneal dialysis in Mexico.

OBJECTIVE: To assess some epidemiological and demographic aspects of peritoneal dialysis (PD) at the Instituto Mexicano del Seguro Social (IMSS), the major institution of social security in Mexico, that provides health care services for 57% of the Mexican population at the time of the study. STUDY DESIGN: A cross-sectional analysis of data about patients under peritoneal dialysis in 1992. DATA SOURCES: A national survey containing demographic data, dialysis modality, type of catheter, peritonitis and death rates, and questions on costs, medical staff, and physical facilities for PD in all of the hospitals of the IMSS. RESULTS: All hospitals returned the information requested. Intermittent peritoneal dialysis (IPD) was performed in 19 hospitals, continuous ambulatory peritoneal dialysis (CAPD) in 11, and both modalities in 90. In 61 hospitals, a special area was designed for PD; in the rest of them, beds from general internal medicine departments were used. All hospitals had a head for the PD programs; overall, teams had 240 physicians and 765 nurses for IPD, and 182 physicians and 313 nurses for CAPD. CAPD prescription was four 2-L bags/day. For IPD, patients were hospitalized once a week and received 28 manually performed exchanges of 2-L bags; the mean time of hospitalization was 2.7 days, and 878 beds were used. The number of patients receiving PD was 7785, with a prevalence of 199.6 per million population. Of them, 4011 were on IPD and 3774 on CAPD; 54% of the patients were males. IPD patients' mean age was 49 +/- 17 yr, and that of CAPD patients' was 42 +/- 17 yr (NS). Diabetic nephropathy was the most frequent cause of ESRD (44%). Infection was the most important complication detected. Rates of peritonitis were 0.5/patient/yr on IPD and 0.8/patient/yr on CAPD. Annual mortality rates without stratification for specific causes were 34% in IPD and 17% in CAPD. Mortality rates may have been influenced by malnutrition and cardiovascular complications of diabetes, but specific causes of death were not investigated. All of the PD programs costs were covered by the institution. The cost per patient was not calculated, but IPD is known to be more expensive, due to its higher hospitalization rate. CONCLUSION: In spite of its higher cost and mortality, the institutions still use IPD, not so much on medical basis, but as the only alternative available for patients with adverse environmental, social, educational, and economic conditions for CAPD or HD.

Outcome of young and elderly diabetic patients on ambulatory peritoneal dialysis: the experience of a community hospital in Puerto Rico.

OBJECTIVE: To analyze the clinical results of a group of young and elderly diabetic patients on ambulatory peritoneal dialysis at a large comprehensive tertiary care community hospital in San Juan, Puerto Rico in relation to rehabilitation characteristics, compliance, complications and survival. DESIGN: The medical records of all patients with a diagnosis of diabetes mellitus trained between June 1985 and June 1992 were reviewed. This group of patients was subdivided according to age, in young (20-50 years) and elderly (50 or over). A comparable number of nondiabetics were selected at random for each of the two age groups. MAIN OUTCOME MEASURES: The patient were studied for age, sex, need of assistance from a partner during dialysis, causes of transfer and hospitalizations, peritonitis, rehabilitation, patients compliance and outcome including mortality. RESULTS: Young diabetics versus non-diabetics: There were 45 patients in the diabetic group (37.8% females) and 57 in the non-diabetic group (54.4% female) with a total observation time of 52.52 patient-months among the diabetics and 82.17 patient-months in the non-diabetic. Mean age of the diabetic patient was 39.9 +/- 8.8 and 36.7 +/- 8.7 for the non-diabetic. Assistance by a partner during the dialysis procedure was needed by 26.7% of the diabetics and by 3.7% of the non-diabetics (p < 0.01). Of the non-diabetics, 91.2% were classified as compliant versus 75.6% of the diabetics (p < 0.05). Peritonitis was the main cause of hospitalizations and of transfers in both groups. The two years patient survival for the diabetic was 81.7% and 100% for the non-diabetic and the two years technique survival was 32.5% for the diabetic and 43.5% for the non-diabetic. Elderly diabetics versus non-diabetics: There were 76 patients in the diabetic group (36.8% female) and 64 in the nondiabetic (43.8% female). The mean age of the diabetic group was 61.3 +/- 6.2 years and 59.3 +/- 7.3 years for the non-diabetic with a total observation time of 81.86 patients-months for the diabetic and 104.58 patient-months for the non-diabetic. Assistance by a partner during dialysis was needed in 63.5% of the diabetics and 19.45% of the non-diabetics (p < 0.01). No statistical difference was found in the rehabilitation or compliance evaluation. Peritonitis stands out again as the main cause of transfer out of the PD modality and main cause of hospitalization in both groups. The two year patient survival for the diabetic was 51.5% and 73.3% for the non-diabetic, while the two years technique survival was 49% for the diabetic and 52.9% for the non-diabetic. CONCLUSIONS: A shortened technique survival, problems of compliance, a high peritonitis rate plus dependency on a partner for dialysis are features of the diabetic group. These findings demonstrate that the diagnosis of diabetes mellitus provides for the development of complications and barriers to the PD modality in both the young and the elderly.

Outcome of young and elderly diabetic patients on ambulatory peritoneal dialysis: the experience of a community hospital in Puerto Rico [see comments]

OBJECTIVE: To analyze the clinical results of a group of young and elderly diabetic patients on ambulatory peritoneal dialysis at a large comprehensive tertiary care community hospital in San Juan, Puerto Rico in relation to rehabilitation characteristics, compliance, complications and survival. DESIGN: The medical records of all patients with a diagnosis of diabetes mellitus trained between June 1985 and June 1992 were reviewed. This group of patients was subdivided according to age, in young (20-50 years) and elderly (50 or over). A comparable number of nondiabetics were selected at random for each of the two age groups. MAIN OUTCOME MEASURES: The patient were studied for age, sex, need of assistance from a partner during dialysis, causes of transfer and hospitalizations, peritonitis, rehabilitation, patients compliance and outcome including mortality. RESULTS: Young diabetics versus non-diabetics: There were 45 patients in the diabetic group (37.8 percent females) and 57 in the non-diabetic group (54.4percent female) with a total observation time of 52.52 patient-months among the diabetics and 82.17 patient-months in the non-diabetic. Mean age of the diabetic patient was 39.9 +/- 8.8 and 36.7 +/- 8.7 for the non-diabetic...

Chronic peritoneal dialysis: seven-year experience in a large Hispanic program.

OBJECTIVE: To analyze the clinical results of our patient population on continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) in relation to treatment modality systems, compliance, rehabilitation characteristics, complications, and survivals. DESIGN: The medical records of all patients trained on CAPD or CCPD between 1985 and 1992 were reviewed for the above-mentioned outcome objectives. SETTING: Outpatient CAPD facility affiliated to a tertiary care community hospital. PATIENTS: The total of 305 patients trained during the study period were studied. MAIN OUTCOME MEASURES: The patients were studied for age, sex, primary renal disease, peritoneal dialysis modality, need of assistance from a partner during the dialysis procedure, causes of transfer and hospitalization, peritonitis, rehabilitation, patient compliance, and outcome including mortality. PATIENT POPULATION: 179 (58.7%) males and 126 (41.3%) females, aged 1-80 years (mean 47.2 +/- 15.09) with a total observation time of 15,753 patient-months. The most common diagnosis of the renal disease was diabetic nephropathy (41%). Peritonitis was the main cause of hospitalizations (36.7%) and of transfers (69.5%). Patient survival at one, two, and three years was 87.9%, 76.6%, and 67.0%, respectively. Likewise, technique survival was 65.5%, 45.5%, and 30.6%. Peritonitis rate for CAPD has improved from 1.9 episodes per patient-year to 1.2 episodes per patient-year and an overall rate of 1.5 episodes per patient-year. CONCLUSIONS: The experience in a large Hispanic program shows a good patient survival rate. Although there is a trend to a lower peritonitis rate, this continues to be the main cause of transfer, hospitalization, and one of the main causes of death.

Three years' clinical experience with chronic ambulatory peritoneal dialysis in San Fernando General Hospital (January 1990 - December 1992) - abstract

From January, 1990 to December, 1993, 33 patients with end-stage renal failure were offered chronic ambulatory peritoneal dialysis (CAPD) after socio-economic, psychiatric and medical evaluation. Main causes of renal failure were: diabetes mellitus/hypertension (13), chronic glomerulonephritis (9), hypertension (6), and other causes (5). Mortality figures ranged from 50 per cent in the first year to 17 per cent in the second year and 9 per cent in the third for one (1) year survival. Causes of death were mainly due to renal failure due to inadequate dialysis, cardio-vascular, diabetic foot gangrene with septicaemia and peritonitis in descending order of frequency. Main complication of dialysis was dialysis-associated peritonitis; other complications were rare. Four (4) patients were converted to haemodialysis because of peritonitis, 2 patients died of peritonitis. Success of dialysis seems to be dependent on availability of fluids, patient motivation and frequent counselling. Eight of the 14 patients alive are gainfully employed and all fourteen (14) lead a good quality of life. CAPD can certainly be recommended for end-stage renal failure on a national health level (AU)

Paediatric dialysis and renal transplantation in the state of Rio Grande do Sul, Brazil.

Renal replacement therapy (RRT) for Brazilian children with uraemia has been utilized since 1970 in the state of Rio Grande do Sul. One hundred and eighty patients receiving this therapy between 1970 and 1988 have been reviewed. The annual acceptance rate of new paediatric patients in this period increased from 0.6 to 6.5 patients per million child population. Glomerulonephritis (36.1%) and pyelonephritis including urological anomalies (31.7%) were the most frequent causes of end-stage renal disease. Outpatient hospital haemodialysis was the primary form of dialytic treatment in patients 5-15 years of age. Continuous ambulatory peritoneal dialysis was more often used in patients less than 5 years of age. The survival after 1 year on dialysis was 79.9% for children aged 5-15 years starting dialysis during the period 1985-1988. Fluid overload with congestive heart failure and infection were the main causes of death in children on dialysis. Eighty-four children received 93 grafts; only 14 (15%) were from cadaveric donors. One-year patient and graft survival of first living-related donor transplants were 92.2% and 78.5% respectively during the period 1985-1988. Infection accounted for 43.5% of deaths after transplantation. We conclude that RRT is becoming increasingly successful for children in our region but that greater emphasis upon patient compliance with all forms of RRT and upon cadaver kidney donation is needed.