We Use Bioincompatible Peritoneal Dialysis Solutions.

Despite advances in peritoneal dialysis (PD) technique and therapy over the last 40 years, PD therapy for end-stage renal disease (ESRD) in the United States remains underutilized. One of the major factors contributing to this underutilization involves concerns about technique failure. More physiologic PD solutions, with a lower concentration of glucose degradation products and a neutral pH, exist and are readily available in Europe, Asia, and Australia. Several benefits of these biocompatible solutions exist over the conventional solutions including a slower decline in residual renal function and better maintenance of urine volumes. There may also be a beneficial effect of the biocompatible solutions in limiting the increase in peritoneal transport that is characteristic of patients maintained on conventional solutions. It should be of concern to the US nephrology community that biocompatible PD solutions are unavailable in the United States.

The chronic kidney disease patient in the acute hospital environment.

CKD is common, affecting more than 10% of the adult US population. Hospital admissions are common among these patients and present challenges for their caregivers. In the acute hospital setting, there is often a lack of awareness of the CKD patient and the best practices developed to help this population. This can place the CKD patient at risk for medication errors such as incorrect dosage or administration of a potentially harmful or unhelpful medication. CKD patients may need procedures during a hospital stay that increase their risk of adverse events. Also, common admission practices such as placing intravenous access needs to be thoughtfully considered in this population.

Patient-specific phosphorus mobilization clearance during nocturnal and short daily hemodialysis.

The kinetics of plasma phosphorus during different hemodialysis (HD) modalities are incompletely understood. We recently demonstrated that a pseudo one-compartment kinetic model including phosphorus mobilization from various body compartments into extracellular fluids can describe intradialytic and postdialytic rebound kinetics of plasma phosphorus during conventional and short 2-hour HD treatments. In this model, individual patient differences in phosphorus kinetics were characterized by a single parameter, the phosphorus mobilization clearance (K(M)). In this report we determined K(M) in patients treated by in-center nocturnal HD (ICNHD) and short daily HD (SDHD) with low dialyzer phosphate clearance. In the ICNHD study, eight patients underwent 8-hour HD treatments where intradialytic and postdialytic plasma samples were collected; K(M) values were determined by nonlinear regression of plasma concentration as a function of time. In the SDHD study, five patients were studied during 28 treatments for approximately 3 hours. Here, K(M) was calculated using only predialytic and postdialytic plasma phosphorus concentrations. Dialyzer phosphate clearances were 134 ± 20 (mean ± SD) and 95 ± 16 mL/min during ICNHD and SDHD, respectively. K(M) values for the respective therapies were 124 ± 83 and 103 ± 33 mL/min, comparable to those determined previously during conventional and short HD treatments of 98 ± 44 mL/min. When results from ICNHD, SDHD, and previous HD modalities were combined, K(M) was directly correlated with postdialytic body weight (r = 0.38, P = 0.025) and inversely correlated with predialytic phosphorus concentration (r = -0.47, P = 0.005). These findings suggest that phosphorus kinetics during various HD modalities can be described by a pseudo one-compartment model.

Factors influencing dialysis modality for end-stage renal disease in developing countries: a survey of Filipino nephrologists.

BACKGROUND: In the Philippines, 86% of incident dialysis patients are started on hemodialysis (HD) and 14% are treated with peritoneal dialysis (PD), representing a decline over a 2-year period. One important factor which affects patients' choice of dialysis modality is the input of their physicians. Our objective was to identify the factors affecting attitudes and recommendations of Filipino nephrologists regarding HD and PD. METHODS: Attendees of the annual national nephrology meeting completed an anonymous self-administered questionnaire. RESULTS: Respondents were heavily involved in clinical dialysis work, and 86.7% had most/all of their patients on HD. Recommendations about dialysis modality were based most strongly on overall cost to patient (4.4 on a scale of 1 [not important] to 5 [most important], residual renal function (RRF) preservation (4.4), patient preference (4.3) availability of dialysis support staff (4.3), and comparative quality of life data (4.3). Least important was physician reimbursement (2.8). Patient-related factors favoring HD were: poor personal hygiene, impaired vision and manual dexterity; while favoring PD were: age <10 years, living far from HD unit, and the availability of trainable family members. When asked which modality they would recommend to an equally eligible patient, 49.2% responded they would not recommend either modality and would allow the patient to choose, while 40.7% would recommend HD and 10.2% would recommend PD. CONCLUSION: Respondents consider overall cost and RRF preservation as the most important factors in dialysis modality selection, yet only 10.2% would recommend PD as first choice. It is likely that factors other than those addressed in the survey are stronger determinants of the patient's final choice of modality.

Trends in chronic peritoneal dialysis utilization in New England.

Utilization of chronic peritoneal dialysis (CPD) continues to decline in the United States. Technique failure remains a key factor in this decline. Center size has been associated with technique failure. Afolalu et al. observed that technique failure rates were higher in units with fewer than 25 patients. We wondered if declining CPD utilization rates are reflective of changes in small or large units. Using the 2000 overall census of individual CPD units in Network #1, New England, between January 1, 2000, and December 31, 2008, we divided the units by size: units with fewer than 25 patients, and units with 25 patients or more. The CPD patient population increased to 1264 patients in 2008 from 1238 patients in 2000 (a 2% increase). A total of 85 units provided CPD therapy in 2000, increasing to 95 units in 2008. Of the 85 units in 2000, 11 managed 25 patients or more. By 2008, 8 of those 11 units had experienced a drop in CPD census. In 2000, larger units had been caring for 547 patients in total; in 2008, larger units were caring for a total of 546 patients. In 2000, 74 units had fewer than 25 patients, and smaller units were caring for a total of 691 patients. By 2008, smaller units were caring for 718 patients in total. Our finding that larger units with 25 patients or more experienced an average decline of 34% in CPD census is a major concern. Growth in the total number of smaller units was not associated with overall CPD growth. Further studies are needed to describe the reasons for decline in CPD census noted in most of the larger units.

Enhanced solute removal with intermittent, in-center, 8-hour nocturnal hemodialysis.

Advances in the dialysis technique and increasing urea Kt/V have not improved outcomes for end-stage renal disease patients maintained on hemodialysis (HD) therapy. Attention has, thus, focused on enhancing solute removal via prolonged HD sessions. A reduction in the serum levels of phosphorus and beta-2-microglobulin (B2M) with longer HD treatments has been linked to improved patient outcomes. We have shown that serum phosphorus levels are significantly lowered in patients maintained on thrice-weekly, in-center, 8-hour nocturnal HD performed at a blood flow rate of 400 mL/min. The kinetics of this modality were examined. A total of 8 patients participated in the study (age 45+/-7 years). Serum creatinine levels decreased from 9.2+/-1.9 to 3.0+/-1.0 mg/dL at 8 hours while serum phosphorus decreased from 5.7+/-1.9 to 2.5+/-0.7 mg/dL at 8 hours. The initial decrease from predialysis values to 1 hour after the start of HD was significant for both creatinine (P<0.0001) and phosphorus (P<0.001). Serum B2M decreased from 26.8+/-5.5 mg/L predialysis to 14.9+/-7.0 mg/L at 8 hours (P<0.01). Dialysate-side clearances of phosphorus and creatinine were 136+/-13 and 143+/-27 cm(3)/min, respectively. Phosphorus clearances were steadily maintained during the 8-hour session. A total of 904+/-292 mg of phosphorus was removed during the 8-hour treatment, with 501+/-174 mg (55%) removed during the first 4 hours and the remaining 45% continuously removed during the latter one-half of the session. The overall calculated B2M clearance was 55.1+/-40.3 cm(3)/min using the immediate post-B2M value and 28.4+/-34.2 mg/L using the 30-minute postdialysis value for the calculation. Serum levels of phosphorus and B2M decrease dramatically during an 8-hour session. Future studies are necessary to determine whether the enhanced solute removal with longer HD sessions translates into an improved outcome for HD patients.

Technique failure and center size in a large cohort of peritoneal dialysis patients in a defined geographic area.

BACKGROUND: Hemodialysis (HD) and peritoneal dialysis (PD) are both viable options for renal replacement therapy. Technique failure has been shown to be a major problem in PD therapy. OBJECTIVE: To examine the relationship between center size and PD technique failure. SETTING: ESRD Network #1 (NW1). DESIGN: Retrospective review of NW1 database. PATIENTS AND METHODS: 5003 incident PD patients between 2001 and 2005 in 105 PD units were included. Patients were grouped into 2 based on center size: group A, patients in units with 25 patients. Outcome measures were analyzed for the first and second years of PD therapy. Patients were censored at transplantation, transfer to HD, or death. OUTCOME MEASURES: Technique failure and mortality reported as death in Standard Information Management Systems (SIMS) database (NW1 data system). RESULTS: Technique failure rates were significantly higher in group A for year 1 (odds ratio: 1.36, p = 0.005) and for year 2 (odds ratio: 1.35, p = 0.03). Mortality rates were not statistically different between the 2 groups. CONCLUSION: Technique failure was higher in units with 25 patients. There was no difference in mortality between the 2 groups. The majority of patients in NW1 receive care in small units.

Taking home dialysis--in-center. Part 1. Managing a successful in-center nocturnal program.

We received an enthusiastic response from patients interested in the nocturnal program at our clinic, and staff willing to work at night. It is a good idea to offer in-center nocturnal dialysis to prevalent patients versus incident patients, because they are used to the therapy. While that may help your program succeed, some patients may still decide that the long hours on dialysis are not comfortable, and may return to standard HD therapy.

Depression and end-stage renal disease: a therapeutic challenge.

Hedayati et al. document a 26.5% incidence of clinical depression and a strong association between depression and hospitalizations and mortality in hemodialysis patients. We can no longer ignore the impact of depression on end-stage renal disease patients. Appropriate therapeutic regimens and trials need to be explored.

A thrice weekly in-center nocturnal hemodialysis program.

The mortality associated with hemodialysis (HD) remains high. Recent studies have found that a session time of 4 to 4.5 hours and an ultrafiltration rate of less than 10 cc/h/kg were each independently associated with a decreased mortality among HD patients. We started a thrice-weekly nocturnal HD program in May 2005 and have since enrolled a total of 16 patients. The Kt/V urea (2.6 +/- 0.65 vs. 1.2 +/- 0.16, mean +/- SD, P < .05) and serum phosphorus (4.4 +/- 1.1 v 5.3 +/-1.3 mg/dL, P =.049) values obtained 6 months after enrollment in the nocturnal HD program were significantly better than the baseline values obtained before the initiation of the nocturnal HD program. The ultrafiltration rate was 5.9 +/- 1.7 mL/h/kg 6 months after patients participated in the nocturnal HD program, whereas the rates for these same patients at baseline was 10.3 +/- 4.5 mL/h/kg. Psychosocial assessments were performed at baseline and again at 6 months. No difference was seen in the results of these assessments. We conclude that patients receiving long, in-center thrice-weekly nocturnal HD have a decrease in serum phosphate, an improvement in urea clearance, and a reduction in ultrafiltration rate to less than 10 mL/h/kg. This therapy appears to have no negative impacts on a variety of quality of life measures.

Effects of home hemodialysis on health-related quality of life measures.

In recent years, there has been an increased interest in performing hemodialysis (HD) more frequently than thrice weekly, particularly in the home setting. This interest has been stimulated by some studies that have indicated significant benefits to performing more frequent HD on various medical and quality of life outcome measures. However, only a few studies using varying quality of life instruments have critically examined the impact of frequent HD on the quality of life of patients. Although not consistent across studies, results suggest a positive impact of more frequent HD on patients' quality of life. It is hoped that the results of two landmark studies, now in progress (the Frequent Hemodialysis Network trial and the FREEDOM study), will provide more insight into the impact of more frequent HD on quality of life.

Complications associated with the development of bacteremia with Staphylococcus aureus.

Access-related infections are a leading cause of morbidity and mortality among hemodialysis patients. Staphylococcus aureus bacteremia accounts for 25% of these episodes. Nissenson et al., found that 20.7% of the patients developing S. aureus bacteremia had infectious complications as well as hospital readmissions related to the S. aureus bacteremia. This retrospective analysis did not determine whether the S. aureus bacteremia was access related, nor how each episode was treated. We have prospectively collected a database of all access-related S. aureus bacteremia developing in our unit between 1/1/03 and 8/31/05, including the management of the access. Episodes of S. aureus bacteremia with an identifiable source other than the vascular access were excluded. Seventy-two episodes of S. aureus bacteremia were identified; 54 developed in patients using a catheter and 18 developed in patients using an arteriovenous graft/fistula. The mean age was 64+/-15 years, and 56% of the patients were Caucasian. All patients were treated with 4 weeks of antibiotics. A total of 6 (8%) deaths and 15 (20.8%) infectious complications related to the S. aureus bacteremia were identified. Infectious complications included endocarditis (4), metastatic infection (7), discitis (3), and a myocardial abscess (1). Seventeen (23.6%) of the patients were readmitted within 30 days of the episode of S. aureus bacteremia; 4 readmissions were related to the S. aureus bacteremia. Five of the 54 catheter patients who developed S. aureus bacteremia expired and 14 developed infectious complications despite the catheter being removed/exchanged in all but one patient. One of the arteriovenous graft patients who developed S. aureus bacteremia expired. We conclude that infectious complications from S. aureus bacteremia are common, as 23.6% of the patients in our study developed an infectious complication. Eight percent of the patients who developed S. aureus bacteremia expired. Strategies to avoid S. aureus bacteremia are needed.

Barriers to utilization of chronic peritoneal dialysis in network #1, New England.

OBJECTIVE: The percentage of prevalent end-stage renal disease (ESRD) patients maintained on chronic peritoneal dialysis (CPD) therapy in the United States declined from 15% in 1991 to 8.1% in 2002. Previous studies indicate that nephrologists in the United States feel 32.6% of prevalent ESRD patients should be on CPD therapy. The present study was designed to better understand the reasons for the discrepancy in actual versus desired prevalence of CPD utilization. METHODS: The medical directors of all dialysis centers in New England were mailed a questionnaire about the nephrologists' opinions concerning the percentage of patients that should be maintained on CPD therapy, reasons that limited patients' selection of CPD as initial therapy, and concerns about the current status of CPD therapy. The nephrologists were also invited to free text any other comments or concerns. RESULTS: A total of 117 questionnaires were sent; 59 (50.4%) were returned. These medical directors cared for a median of 10 (range 1 - 100) patients on CPD therapy, meaning 15% of dialysis patients in New England are maintained on CPD therapy. The medical directors felt that 29% (range 10% - 50%) of prevalent ESRD patients should be maintained on CPD therapy. The most common reasons cited by the nephrologists as barriers to CPD therapy included patient preference (54%), contraindications to performing CPD therapy (32%), poor social support (31%), significant comorbid disease (20%), late referrals and acute hospital starts (19%), problems with education re chronic kidney disease (12%), and problems with the structure and organization of CPD facilities (12%). These same medical directors stated that concerns about technique failure (25%), long-term viability of CPD therapy (25%), and mortality rates of CPD patients (17%) impacted on their use of CPD therapy as renal replacement therapy for patients with ESRD. CONCLUSION: Nephrologists in New England felt that 29% of prevalent ESRD patients should be maintained on CPD therapy, yet the actual incidence of CPD utilization in New England is 15%. A variety of factors were cited by the nephrologists as important reasons limiting CPD utilization. These nephrologists were also concerned about technique failure and long-term viability of CPD therapy. It is necessary that we look closely at each domain cited by the nephrologists if CPD therapy is to remain a viable option for patients with ESRD in the United States.

The role of chronic peritoneal dialysis in the management of the patient with chronic kidney disease.

The role of chronic peritoneal dialysis (CPD) in the management of patient with chronic kidney disease is being reexamined. There has been a decline in CPD utilization in the United States, which has been attributed to a variety of factors. It is important that these factors be understood and addressed, since nephrologists feel that about 30% of end-stage renal disease patients should be maintained on CPD and patients are more satisfied with CPD and feel that CPD has a less negative impact on their lives than hemodialysis. The present chapter discusses some of the reasons for decline in CPD utilization in the United States.

Treatment and outcome of CPD-associated peritonitis.

CPD-associated peritonitis is a leading cause of morbidity and mortality for ESRD patients maintained on CPD therapy. The percentage of ESRD patients maintained on CPD therapy is declining. The reasons are unclear, but may be due to concerns about CPD-associated peritonitis. The incidence of CPD-associated peritonitis has decreased largely attributed to technical advances and the identification of risk factors including exit-site infection, colonization with Staphylococcus aureus and depression. The typical spectrum of organisms causing peritonitis include gram-positive organisms (67%), gram-negative organisms (28%), fungi (2.5%) or anaerobic organisms (2.5%). Culture-negative episodes do occur: up to 20% of the episodes of peritonitis in some series are culture-negative. The treatment of CPD associated peritonitis is rather standardized with current recommendations by the International Society of Peritoneal Dialysis universally adopted. Approximately 80% of the patients developing peritonitis will respond to antimicrobial therapy and remain on CPD therapy, while 10 to 15% of the patients require catheter removal and transfer to hemodialysis. Approximately 6% of the patients expire as a result of peritonitis. The outcome is different based on organism with gram-negative and fungal episodes having a worse outcome than gram-positive episodes. The development of CPD-associated peritonitis can be linked to traditional risk factors such as exit-site infection and poor technique. Bacterial biofilm has also been suggested as a cause of peritonitis. Our current antimicrobial protocols may not permit adequate dosing to penetrate the biofilm and be a reason for recurrent or repeat episodes of peritonitis. It is important that we improve our understanding of factors responsible for the development and outcome of CPD-associated peritonitis in order for this renal replacement therapy to remain a viable option for patients with ESRD.

Course of C-reactive protein during continuous peritoneal dialysis-associated peritonitis.

OBJECTIVE: C-reactive protein (CRP) levels increase during peritonitis. Little is known about the extent and duration of CRP elevation. PATIENTS AND METHODS: Patients on continuous peritoneal dialysis (CPD) therapy had a baseline CRP value at the start of the study. CRP values were determined at 48 h, 2 weeks and 4 weeks after an episode of peritonitis developed in the 13 months after the study started. RESULTS: The demographic values and comorbid diseases of the patients developing and not developing peritonitis were not significantly different. Patients who developed peritonitis had a mean +/- SD CRP value of 15.0 +/- 11.1 mg/L compared with 15.7 +/- 9.9 mg/L in patients without peritonitis. The CRP value rose to 118.35 +/- 96.86 mg/L at 48 h, and decreased to 34.5 +/- 43.6 mg/L at 2 weeks and to 30.1 +/- 39.7 mg/L at 4 weeks after the onset of peritonitis. All types of peritonitis were associated with a significant increase in CRP at 48 h. Nine patients had CRP elevations above baseline at 4 weeks; seven patients had active medical issues. CONCLUSION: CRP values become significantly elevated during peritonitis. Most patients have a decrease in the CRP values toward baseline values at 4 weeks following the onset of peritonitis while 20% of patients had continued elevations. The significance of the elevations is unclear. Given the associations of CRP with cardiovascular mortality in both uremic and non-uremic patients and the association of peritonitis with mortality, the role of this inflammatory marker deserves further evaluation.