Opportunities to improve the management of anemia in peritoneal dialysis patients: lessons from a national study in routine clinical practice.

Background: Current guidelines establish the same hemoglobin (Hb) and iron biomarkers targets for hemodialysis (HD) and peritoneal dialysis (PD) in patients receiving erythropoiesis-stimulating agents (ESAs) even though patients having PD are usually younger, more active and less comorbid. Unfortunately, specific renal anemia [anemia in chronic kidney disease (aCKD)] trials or observational studies on PD are scanty. The aims of this study were to describe current aCKD management, goals and adherence to clinical guidelines, identifying opportunities for healthcare improvement in PD patients. Methods: This was a retrospective, nationwide, multicentre study including patients from 19 PD units. The nephrologists collected baseline data, demographics, comorbidities and data related to anemia management (laboratory values, previously prescribed treatments and subsequent adjustments) from electronic medical records. The European adaptation of KDIGO guidelines was the reference for definitions, drug prescriptions and targets. Results: A total of 343 patients (mean age 62.9 years, 61.2% male) were included; 72.9% were receiving ESAs and 33.2% iron therapy [20.7% intravenously (IV)]. Eighty-two patients were receiving ESA without iron therapy, despite 53 of them having an indication according to the European Renal Best Practice guidelines. After laboratory results, iron therapy was only started in 15% of patients. Among ESA-treated patients, 51.9% had an optimal control [hemoglobin (Hb) 10-12 g/dL] and 28.3% between 12-12.9 g/dL. Seventeen patients achieved Hb >13 g/dL, and 12 of them remained on ESA after overshooting. Only three patients had Hb <10 g/dL without ESAs. Seven patients (2%) met criteria for ESA resistance (epoetin dose >300 IU/kg/week). The highest tertile of erythropoietin resistance index (>6.3 UI/kg/week/g/dL) was associated with iron deficiency and low albumin corrected by renal replacement therapy vintage and hospital admissions in the previous 3 months. Conclusion: Iron therapy continues to be underused (especially IV). Low albumin, iron deficiency and prior events explain most of the ESA hyporesponsiveness. Hb targets are titrated to/above the upper limits. Thus, several missed opportunities for adequate prescriptions and adherence to guidelines were identified.

Safety and effectiveness of sucroferric oxyhydroxide in Spanish patients on dialysis: sub-analysis of the VERIFIE study.

BACKGROUND AND AIMS: In this study, we show the results of the subset of Spanish patients of the VERIFIE study, the first post-marketing study assessing the long-term safety and effectiveness of sucroferric oxyhydroxide (SFOH) in patients with hyperphosphatemia undergoing dialysis during clinical practice. PATIENTS AND METHODS: Patients undergoing hemodialysis and peritoneal dialysis with indication of SFOH treatment were included. Follow-up duration was 12-36 months after SFOH initiation. Primary safety variables were the incidence of adverse drug reactions (ADRs), medical events of special interest (MESIs), and variations in iron-related parameters. SFOH effectiveness was evaluated by the change in serum phosphorus levels. RESULTS: A total of 286 patients were recruited and data from 282 were analyzed. Among those 282 patients, 161 (57.1%) withdrew the study prematurely and 52.5% received concomitant treatment with other phosphate binders. ADRs were observed in 35.1% of patients, the most common of which were gastrointestinal disorders (77.1%) and mild/moderate in severity (83.7%). MESIs were reported in 14.2% of patients, and 93.7% were mild/moderate. An increase in ferritin (386.66ng/mL vs 447.55ng/mL; p=0.0013) and transferrin saturation (28.07% vs 30.34%; p=0.043) was observed from baseline to the last visit (p=0.0013). Serum phosphorus levels progressively decreased from 5.69mg/dL at baseline to 4.84mg/dL at the last visit (p<0.0001), increasing by 32.2% the proportion of patients who achieved serum phosphorus levels ≤5.5mg/dL, with a mean daily SFOH dose of 1.98 pills/day. CONCLUSIONS: SFOH showed a favorable effectiveness profile, a similar safety profile to that observed in the international study with most adverse events of mild/moderate severity, and a low daily pill burden in Spanish patients in dialysis.

Prominent Levels of the Profibrotic Chemokine CCL18 during Peritonitis: In Vitro Downregulation by Vitamin D Receptor Agonists.

Peritoneal dialysis (PD) is used as a renal replacement therapy, which can be limited by peritoneal membrane ultrafiltration failure (UFF) secondary to fibrotic processes. Peritonitis, a frequent complication of PD, is a major risk factor for peritoneal membrane fibrosis and UFF. Low peritoneal levels of the chemokine CCL18 are associated with preservation of peritoneal membrane function in PD. Given that CCL18 is involved in fibrotic processes and recurrent peritonitis, it is a risk factor for peritoneal membrane failure; thus, we evaluated CCL18 concentrations in peritoneal effluents from patients undergoing peritonitis episodes. Pharmacological interventions aimed at diminishing the production of CCL18 were also explored. Fivefold higher CCL18 peritoneal concentrations were found during acute bacterial peritonitis, in parallel with the increased infiltration of macrophages. Unexpectedly, CCL18 was also highly (50-fold) increased during sterile eosinophilic peritonitis, and peritoneal eosinophils were found to express CCL18. In vitro treatment of peritoneal macrophages with the vitamin D receptor agonist paricalcitol was able to reduce the secretion and the expression of CCL18 in isolated peritoneal macrophages. In conclusion, our study suggests that the chemokine CCL18 can be a mediator of peritoneal membrane failure associated with peritonitis episodes as well as providing a new potential therapeutic target.

Paricalcitol and Peritoneal Protein Loss in Peritoneal Dialysis: A Double-Center Study.

BACKGROUND/AIMS: Peritoneal protein loss (PPL) is associated with cardiovascular disease and mortality in peritoneal dialysis (PD). Controversial results have been published about the effect of paricalcitol in PPL among PD patients. This study intends to analyze the relationship between paricalcitol and PPL in PD. METHODS: In a retrospective study, prevalent PD patients were divided into 2 groups: "with paricalcitol" and "without paricalcitol". X2-test, Student's t test, Pearson correlation coefficient and Logistic Regression analysis were applied. RESULTS: Eighty-two patients were included. PPL was lower among patients medicated with paricalcitol (5.17 ± 1.71 vs. 6.79 ± 2.10 g/24 h, p = 0.0001). In multivariate analysis, paricalcitol and dialysate/plasma ratio of creatinine (D/P creatinine) were independently related to PPL (OR 4.270 [1.437-12.684], p = 0.009 and OR 0.205 [0.064-0.659], p = 0.008, respectively), adjusted for diabetes. CONCLUSION: Paricalcitol and D/P creatinine were independently related to PPL. Paricalcitol may have an effect on PPL in PD patients.

Relationship between bioimpedance-determined body composition and peritoneal transport in peritoneal dialysis.

PURPOSE: In peritoneal dialysis (PD) patients, body fluid homeostasis is dependent on peritoneal elimination of water and solutes. Patients with less favorable peritoneal transport parameters should be more overhydrated. Despite this, the association between faster transport and overhydration (OH) is weak, and the factors that influence hydration status are still poorly characterized. Modified peritoneal equilibration tests (PET) offer us new parameters that might correlate better with hydration status, like free water transport (FWT). The aim of this study was thus to establish the relationships between new peritoneal transport parameters and body composition parameters estimated by bioimpedance spectroscopy (BIS). METHODS: Prospective observational study on incident PD patients with a baseline and 1-year follow-up evaluation. RESULTS: 61 patients were included in the baseline evaluation, 19 of whom had a 1-year follow-up evaluation; 67.2% were fluid overloaded. There was a negative correlation between D/P creatinine and FWT (r = -0.598, p = 0.000). The fraction of FWT was negatively correlated with OH (r = -0.302, p = 0.018). Peritoneal protein losses (PPL) were also correlated with OH (r = 0.287, p = 0.028). There were no significant differences in OH according to small-solute transport status or fluid output parameters. After 1 year, we observed a significant worsening of renal function and an improvement in 24-hour ultrafiltration (UF) and hydration status, but we detected no differences in peritoneal transport of water or solutes that could explain these changes. CONCLUSIONS: There is a poor relationship between kidney/peritoneal function parameters and body composition parameters. The fraction of FWT and PPL may be underestimated markers of peritoneal health and of its contribution to the hydration status.

Sustained low peritoneal effluent CCL18 levels are associated with preservation of peritoneal membrane function in peritoneal dialysis.

Peritoneal membrane failure (PMF) and, ultimately, encapsulating peritoneal sclerosis (EPS) are the most serious peritoneal dialysis (PD) complications. Combining clinical and peritoneal transport data with the measurement of molecular biomarkers, such as the chemokine CCL18, would improve the complex diagnosis and management of PMF. We measured CCL18 levels in 43 patients' effluent and serum at baseline and after 1, 2, and 3 years of PD treatment by retrospective longitudinal study, and evaluated their association with PMF/EPS development and peritoneal risk factors. To confirm the trends observed in the longitudinal study, a cross-sectional study was performed on 61 isolated samples from long-term (more than 3 years) patients treated with PD. We observed that the patients with no membrane dysfunction showed sustained low CCL18 levels in peritoneal effluent over time. An increase in CCL18 levels at any time was predictive of PMF development (final CCL18 increase over baseline, p = .014; and maximum CCL18 increase, p = .039). At year 3 of PD, CCL18 values in effluent under 3.15 ng/ml showed an 89.5% negative predictive value, and higher levels were associated with later PMF (odds ratio 4.3; 95% CI 0.90-20.89; p = .067). Moreover, CCL18 levels in effluent at year 3 of PD were independently associated with a risk of PMF development, adjusted for the classical (water and creatinine) peritoneal transport parameters. These trends were confirmed in a cross-sectional study of 61 long-term patients treated with PD. In conclusion, our study shows the diagnostic capacity of chemokine CCL18 levels in peritoneal effluent to predict PMF and suggests CCL18 as a new marker and mediator of this serious condition as well as a new potential therapeutic target.

Composición corporal y concentraciones de adipocitoquinas en hemodiálisis: la ganancia de grasa abdominal como factor de riesgo cardiovascular añadido / Body composition analysis and adipocytokine concentrations in haemodialysis patients: abdominal fat gain as an additional cardiovascular risk factor

Introducción: La grasa abdominal y, sobre todo, su ganancia a lo largo del tiempo, se ha consolidado como un factor de riesgo cardiovascular en pacientes urémicos. Objetivos: Analizar los cambios en la grasa abdominal en los pacientes de hemodiálisis (HD) a lo largo de un año y estudiar sus posibles relaciones con los cambios en los niveles circulantes de adipocitocinas. Como objetivo secundario intentamos validar los datos obtenidos por bioimpedancia eléctrica (BIA) con los obtenidos por absorciometría dual de rayos X (DXA). Material y métodos: Se realizó un estudio prospectivo de un año de duración en 18 pacientes en HD. En cada paciente se cuantificó, basalmente y al cabo de un año, la composición corporal por BIA y DXA y se determinaron varios parámetros bioquímicos incluyendo adipocitocinas. Resultados: Se evidenció un aumento significativo del ángulo de fase [4,8° (4,1-5,6) frente a 5,2° (4,4-5,8); p<0,05], del agua intracelular por BIA [48,3% (43,1-52,3) frente a 50,3% (45,7-53,4); p<0,05] y del cociente entre el porcentaje de grasa de distribución androide/ginecoide (A/G) medido por DXA [1,00 (0,80-1,26) frente a 1,02 (0,91; 1,30); p<0,05]. Se encontró una relación estadísticamente significativa entre las concentraciones de leptina y adiponectina tanto con el porcentaje de masa grasa medida por BIA como con la grasa abdominal estimada mediante DXA (p<0,01). Conclusión: Los pacientes en HD experimentan una ganancia de grasa con el tiempo, especialmente en localización abdominal, evidenciada por un aumento del cociente A/G, lo que podría explicar el aumento del riesgo cardiovascular que presentan (AU)

Introduction: Abdominal fat and its increment over time in particular has become a cardiovascular risk factor in uraemic patients. Objectives: To analyse changes in abdominal fat in haemodialysis patients over one year and study their possible correlation with the variation in adipocytokine serum levels. As a secondary objective, we tried to validate the data obtained by bioelectrical impedance analysis (BIA) with data obtained by dual X-ray absorptiometry (DXA). Material and methods: A prospective one-year study was performed in 18 patients on haemodialysis (HD). In each patient, body composition by BIA and DXA was estimated at baseline and after one year. Several adipocytokine and biochemical parameters were determined. Results: A significant increase in phase angle [4.8° (4.1-5.6) vs. 5.2° (4.4-5.8), P<.05], BIA intracellular water [48.3% (43.1-52.3) vs. 50.3% (45.7-53.4), P<.05] and the ratio between the percentage of android/gynecoid (A/G) distribution of fat measured by DXA [1.00 (0.80-1.26) vs. 1.02 (0.91-1.30), P<.05] was observed. A statistically significant relationship between leptin and adiponectin concentrations and the percentage of fat mass measured by BIA, as well as the abdominal fat percentage estimated by DXA, was found (P<.01). Conclusion: HD patients exhibit a gain in fat mass over time, especially in the abdomen, evidenced by an increased A/G ratio. These findings might explain the increased cardiovascular risk in these patients (AU)

Genomic reprograming analysis of the Mesothelial to Mesenchymal Transition identifies biomarkers in peritoneal dialysis patients.

Peritoneal dialysis (PD) is an effective renal replacement therapy, but a significant proportion of patients suffer PD-related complications, which limit the treatment duration. Mesothelial-to-mesenchymal transition (MMT) contributes to the PD-related peritoneal dysfunction. We analyzed the genetic reprograming of MMT to identify new biomarkers that may be tested in PD-patients. Microarray analysis revealed a partial overlapping between MMT induced in vitro and ex vivo in effluent-derived mesothelial cells, and that MMT is mainly a repression process being higher the number of genes that are down-regulated than those that are induced. Cellular morphology and number of altered genes showed that MMT ex vivo could be subdivided into two stages: early/epithelioid and advanced/non-epithelioid. RT-PCR array analysis demonstrated that a number of genes differentially expressed in effluent-derived non-epithelioid cells also showed significant differential expression when comparing standard versus low-GDP PD fluids. Thrombospondin-1 (TSP1), collagen-13 (COL13), vascular endothelial growth factor A (VEGFA), and gremlin-1 (GREM1) were measured in PD effluents, and except GREM1, showed significant differences between early and advanced stages of MMT, and their expression was associated with a high peritoneal transport status. The results establish a proof of concept about the feasibility of measuring MMT-associated secreted protein levels as potential biomarkers in PD.

Body composition analysis and adipocytokine concentrations in haemodialysis patients: abdominal fat gain as an additional cardiovascular risk factor. / Composición corporal y concentraciones de adipocitoquinas en hemodiálisis: la ganancia de grasa abdominal como factor de riesgo cardiovascular añadido.

INTRODUCTION: Abdominal fat and its increment over time in particular has become a cardiovascular risk factor in uraemic patients. OBJECTIVES: To analyse changes in abdominal fat in haemodialysis patients over one year and study their possible correlation with the variation in adipocytokine serum levels. As a secondary objective, we tried to validate the data obtained by bioelectrical impedance analysis (BIA) with data obtained by dual X-ray absorptiometry (DXA). MATERIAL AND METHODS: A prospective one-year study was performed in 18 patients on haemodialysis (HD). In each patient, body composition by BIA and DXA was estimated at baseline and after one year. Several adipocytokine and biochemical parameters were determined. RESULTS: A significant increase in phase angle [4.8° (4.1-5.6) vs. 5.2° (4.4-5.8), P<.05], BIA intracellular water [48.3% (43.1-52.3) vs. 50.3% (45.7-53.4), P<.05] and the ratio between the percentage of android/gynecoid (A/G) distribution of fat measured by DXA [1.00 (0.80-1.26) vs. 1.02 (0.91-1.30), P<.05] was observed. A statistically significant relationship between leptin and adiponectin concentrations and the percentage of fat mass measured by BIA, as well as the abdominal fat percentage estimated by DXA, was found (P<.01). CONCLUSION: HD patients exhibit a gain in fat mass over time, especially in the abdomen, evidenced by an increased A/G ratio. These findings might explain the increased cardiovascular risk in these patients.

The Communication and Bioethical Training (CoBiT) Program for assisting dialysis decision-making in Spanish ACKD units.

Healthcare professionals currently working in Advanced Chronic Kidney Disease (ACKD) units must cope with difficult situations regarding assisting patients with the dialysis decision-making process, and they are often untrained for these conversations. Although we have evidence from the literature that these skills can be learned, few professionals feel confident in this area. A Communication and Bioethical Training (CoBiT) Program for ACKD staff (physicians, nurses and allied health professionals) was developed to improve their ability and self-confidence in conducting these conversations. A four-stage study was conducted: (1) development of the CoBiT program, beginning with the creation of an interdisciplinary focus group (N = 10); (2) design of a questionnaire to assess self-confidence based on the areas identified by the focus group. The face validity of the instrument was tested using an inter-judge methodology (N = 6); (3) design of the format and contents of the program; (4) piloting the program. Thirty-six health professionals took an 8-h workshop based on role-playing methodology. Participants assessed their self-confidence in their communication skills before and after the program using self-report measures. The results show that after the program, participants reported significantly higher levels of self-confidence measured with a five-point Likert scale (p < 0.001). Participants felt that communication with colleagues of other professions significantly increased after the workshop (p = 0.004). The CoBiT program improves ACKD Unit healthcare professionals' self-confidence in their ability to perform a specific communication task.

Thyroid dysfunction and kidney disease: An update.

Thyroid hormones influence renal development, kidney hemodynamics, glomerular filtration rate and sodium and water homeostasis. Hypothyroidism and hyperthyroidism affect renal function by direct renal effects as well as systemic hemodynamic, metabolic and cardiovascular effects. Hypothyroidism has been associated with increased serum creatinine and decreased glomerular filtration rate. The reverse effects have been reported in thyrotoxicosis. Most of renal manifestations of thyroid dysfunction are reversible with treatment. Kidney disease may also cause thyroid dysfunction by several mechanisms. Nephrotic syndrome has been associated to changes in serum thyroid hormone concentrations. Different forms of glomerulonephritis and tubulointerstitial disease may be linked to thyroid derangements. A high prevalence of thyroid hormone alteration has been reported in acute kidney injury. Thyroid dysfunction is highly prevalent in chronic kidney disease patients. Subclinical hypothyroidism and low triiodothyronine syndrome are common features in patients with chronic kidney disease. Patients treated by both hemodialysis and peritoneal dialysis, and renal transplantation recipients, exhibit thyroid hormone alterations and thyroid disease with higher frequency than that found in the general population. Drugs used in the therapy of thyroid disease may lead to renal complications and, similarly, drugs used in kidney disorders may be associated to thyroid alterations. Lastly, low thyroid hormones, especially low triiodothyronine levels, in patients with chronic kidney disease have been related to a higher risk of cardiovascular disease and all-cause mortality. Interpretation of the interactions between thyroid and renal function is a challenge for clinicians involved in the treatment of patients with thyroid and kidney disease.

Cómo debemos analizar y describir la mortalidad de nuestros pacientes: experiencia del Grupo Centro Diálisis Peritoneal / How should we analyze and present mortality in our patients?: A multicentre GCDP experience

Introducción: Existen distintas estrategias para analizar la mortalidad en diálisis peritoneal (DP), con diferentes definiciones de caso, evento, tiempo en riesgo y análisis estadístico. Un método común entre los distintos registros permitiría compararlos adecuadamente y entender mejor las diferencias reales de mortalidad de nuestros pacientes. Métodos: Revisamos y describimos las estrategias de análisis de los registros autonómicos, nacional e internacionales. Incluimos análisis de supervivencia actuarial, Kaplan-Meier (KM) y riesgos-competitivos (RC). Aplicamos los diferentes enfoques a la misma base de datos (GCDP), lo que permite mostrar las diferencias aparentes con cada método. Resultados: Se incluyeron 1.890 pacientes incidentes en DP en el periodo 2003-2013 (55 años; 64,2% varones), con FRR inicial de 7ml/min; el 25% presentaba diabetes y un índice de Charlson de 3 [2-4]. Fallecieron 261 pacientes, 380 pasaron a hemodiálisis (HD) y 682 recibieron trasplante. Las tasas de mortalidad anual llegan a variar hasta un 20% en números relativos (6,4 vs. 5,2%) según el sistema aplicado. La estimación de probabilidad de mortalidad por RC es inferior a KM en todos los años: 3,6 vs. 4,0% el 1.er año; 9,0 vs. 11,9%; 15,6 vs. 28,3% y 18,5 vs. 43,3% los siguientes. Conclusiones: Aunque cada método pueda ser correcto en sí mismo y expresar diferentes enfoques, la impresión final que queda en el lector es un número que sobrestima la mortalidad. El modelo de RC expresa mejor la realidad en DP, donde el número de pacientes que pierden seguimiento (trasplante, paso a HD) cuadruplica al de los fallecidos y solo una cuarta parte continúa en DP al final del seguimiento (AU)

Introduction: There are different strategies to analyse mortality in peritoneal dialysis (PD) with different definitions for case, event, time at risk, and statistical tests. A common method for the different registries would enable proper comparison to better understand the actual differences in mortality of our patients. Methods: We review and describe the analysis strategies of regional, national and international registries. We include actuarial survival, Kaplan-Meier (KM) and competitive risk (CR) analyses. We apply different approaches to the same database (GCDP), which show apparent differences with each method. Results: A total of 1,890 incident patients in PD from 2003-2013 were included (55 years; men 64.2%), with initial RRF of 7 ml/min; 25% had diabetes and a Charlson index of 3 [2-4]; 261 patients died, 380 changed to haemodialysis (HD) and 682 received a transplant. Annual mortality rates varied up to 20% in relative numbers (6.4 vs. 5.2%) depending on the system applied. The estimated probability of mortality measured by CR progressively differs from the KM over the years: 3.6 vs. 4.0% the first year, then 9.0 vs. 11.9%, 15.6 vs. 28.3%, and 18.5 vs. 43.3% the following years. Conclusions: Although each method may be correct in themselves and express different approaches, the final impression left on the reader is a number that under/overestimates mortality. The CR model better expresses the reality of PD, where the number of patients lost to follow-up (transplant, transfer to HD) it is 4 times more than deceased patients and only a quarter remain on PD at the end of follow up (AU)

How should we analyze and present mortality in our patients?: A multicentre GCDP experience.

INTRODUCTION: There are different strategies to analyse mortality in peritoneal dialysis (PD) with different definitions for case, event, time at risk, and statistical tests. A common method for the different registries would enable proper comparison to better understand the actual differences in mortality of our patients. METHODS: We review and describe the analysis strategies of regional, national and international registries. We include actuarial survival, Kaplan-Meier (KM) and competitive risk (CR) analyses. We apply different approaches to the same database (GCDP), which show apparent differences with each method. RESULTS: A total of 1,890 incident patients in PD from 2003-2013 were included (55 years; men 64.2%), with initial RRF of 7ml/min; 25% had diabetes and a Charlson index of 3 [2-4]; 261 patients died, 380 changed to haemodialysis (HD) and 682 received a transplant. Annual mortality rates varied up to 20% in relative numbers (6.4 vs. 5.2%) depending on the system applied. The estimated probability of mortality measured by CR progressively differs from the KM over the years: 3.6 vs. 4.0% the first year, then 9.0 vs. 11.9%, 15.6 vs. 28.3%, and 18.5 vs. 43.3% the following years. CONCLUSIONS: Although each method may be correct in themselves and express different approaches, the final impression left on the reader is a number that under/overestimates mortality. The CR model better expresses the reality of PD, where the number of patients lost to follow-up (transplant, transfer to HD) it is 4 times more than deceased patients and only a quarter remain on PD at the end of follow up.

Biocompatible Dialysis Solutions Preserve Peritoneal Mesothelial Cell and Vessel Wall Integrity. A Case-Control Study on Human Biopsies.

UNLABELLED: ♦ INTRODUCTION: Chronic exposure to conventional peritoneal dialysis (PD) solutions has been related to peritoneal function alterations in PD patients, and associated with mesothelial cell loss, submesothelial fibrosis, vasculopathy, and angiogenesis. In vitro and ex vivo analyses, as well as studies with animal models, have demonstrated that biocompatible PD solutions attenuate these morphological alterations. Our aim was to confirm the morphological benefits of biocompatible solutions in PD patients. ♦ METHODS: We analyzed biopsies from 23 patients treated with biocompatible solutions (study group, SG), and compared them with a control group (n = 23) treated with conventional solutions (CG), matched for time on PD. ♦ RESULTS: A total of 56.5% of SG patients showed total or partial preservation of mesothelial cells monolayer, in contrast with 26.1% of patients in CG (p = 0.036). Peritoneal fibrosis was not significantly less frequent in SG patients (47.8% SG vs 69.6% CG; p = 0.13). In patients without previous peritonitis, a significantly lower prevalence of fibrosis was present in SG patients (41.7% SG vs 77.8% CG; p = 0.04). Hyalinizing vasculopathy (HV) was significantly lower in SG (4.3% SG vs 30.4% CG; p = 0.02). Cytokeratin-positive fibroblast-like cells were detected in 10 patients (22%), but the prevalence was not significantly lower in SG. In the univariate regression analysis, the use of biocompatible solutions was associated with mesothelial monolayer integrity (p = 0.04) and an absence of vasculopathy (p = 0.04). ♦ CONCLUSION: The present study demonstrates in vivo in human biopsies that biocompatible solutions are better tolerated by the peritoneum in the medium and long term than conventional solutions.

An Increase of Plasma Advanced Oxidation Protein Products Levels Is Associated with Cardiovascular Risk in Incident Peritoneal Dialysis Patients: A Pilot Study.

Advanced oxidation protein products (AOPPs) are considered as markers and even mediators of the proinflammatory effect of oxidative stress in uremia. We hypothesized that an increase of oxidative stress associated with peritoneal dialysis (PD), estimated by the variation of plasma AOPPs over time, might be associated with cardiovascular (CV) risk and overall prognosis. In 48 PD patients, blood samples were collected on two occasions: the first one in the first six months after starting PD therapy and the second one, one year after. The plasma AOPPs level variation over the first year on PD was significantly associated with CV antecedents and also with CV prognosis. In those patients in whom the AOPPs levels increased more than 50% above the baseline value, a significant association with past and future CV disease was confirmed. These patients had 4.7 times greater risk of suffering later CV disease than those with a smaller increase, even after adjusting for previous CV history. Our data suggest that the increase of AOPPs plasma level over the first year on PD is conditioned by CV antecedents but also independently predicts CV prognosis. AOPPs plasma levels seem to represent the CV status of PD patients with sufficient sensitivity to identify those with a clearly sustained higher CV risk.

Vectores de impedancia bioeléctrica de referencia para la población española / Normal values of bioimpedance vector in Spanish population

Fundamento y objetivo: El análisis de vectores de impedancia es útil para la determinación de la composición corporal en pacientes con alteración del estado de hidratación. Las elipses de tolerancia originales fueron hechas en individuos sanos italianos. Debido a las diferencias en composición corporal entre poblaciones, el objetivo del estudio fue establecer elipses de tolerancia específicas para la población española y compararlas con las elipses realizadas en la población original de referencia. Material y método: Se estudiaron 311 sujetos sanos españoles de ambos sexos, entre 18 y 80 años, con IMC entre 18 y 31 Kg/m2 , a los cuales se les realizaron mediciones de peso, estatura e impedancia bioeléctrica. Los valores de resistencia y reactancia estandarizadas por la estatura (R/E y Xc/E) derivados de la medición de impedancia, fueron utilizados para determinar la composición corporal y realizar las elipses de referencias específicas para dicha población. Resultados: Las características de composición corporal fueron diferentes entre sexos y grupo etario. Se graficaron los valores de R/E y Xc/E de la población española sobre las elipses de tolerancia italianas, encontrándose que los vectores se situaban en los cuadrantes izquierdos, indicando diferente composición corporal, por lo que se construyeron elipses de tolerancia específicas para la población española a partir de los valores de R/E y Xc/E. Las elipses de tolerancia españolas fueron estadísticamente diferentes a las italianas. Conclusiones: Los vectores de la población española fueron diferentes a los de la población italiana, de ahí la importancia de tener un patrón de referencia propio (AU)

Background and objective: The bioelectrical impedance vector analysis is useful for the determination of body composition in patients with altered hydration status. The original tolerance ellipses were made in Italian healthy individuals. Due to differences in body composition between populations, the aim of the study was to establish specific tolerance ellipses for the Spanish population and compare them with those ellipses made in the original reference population. Methods: We studied 311 Spanish healthy subjects of both sexes, between 18 and 80 years old, with a BMI between 18 and 31 Kg/m2, who underwent measurements of weight, height and bioelectrical impedance. The values of resistance and reactance standardized by height (R/H and Xc/H) derived from the impedance measurement, were used to determine the body composition and construct the specific tolerance ellipses for this population. Results: The characteristics of body composition were different between sex and age groups. We plotted values of R/H and Xc/H of the Spanish population on the Italian tolerance ellipses finding that vectors were placed in left quadrants, indicating different body composition. We therefore built specific tolerance ellipses for Spanish population based on values of R/H and Xc/H. Spanish tolerance ellipses were statistically different from the Italian. Conclusions: The vectors of the Spanish population were different from those of the Italian, hence the importance of having a self-reference pattern (AU)

Peritoneal resting with heparinized lavage reverses peritoneal type I membrane failure. A comparative study of the resting effects on normal membranes.

BACKGROUND: Ultrafiltration failure (UFF) is a serious complication of long-term peritoneal dialysis (PD). Peritoneal rest (PR) has been demonstrated as a valid treatment to reverse the functional changes that occur in UFF. The effects of PR on a normally functioning human peritoneum are unknown but are expected to be neutral. Our hypothesis was that PR positively modifies peritoneal function in patients with UFF, in contrast to the absence of effects when PR is applied under normal conditions. PATIENTS AND METHODS: We studied 84 PR periods, comparing 35 patients with UFF and 49 controls (resting for abdominal surgery with temporary discontinuation of PD). We analyzed peritoneal transport pre-PR and post-PR by calculating the mass transfer coefficients of creatinine (Cr-MTAC), the dialysate/plasma creatinine ratio (D/P Cr) and the ultrafiltration (UF). RESULTS: Baseline data was similar for the 2 groups, although the UFF group had a longer median time in PD (39 [18 - 60] vs 10 [5 - 23] months; p = 0.00001). Peritoneal rest induced a decrease in D/P Cr, Cr-MTAC and an increase in UF capacity in the UFF group (p = 0.0001, p = 0.004 and p = 0.001, respectively), without causing changes in the control group. Peritoneal rest in patients with more than 6 months of UFF was not able to reduce peritoneal solute transport or improve UF capacity. Response to PR did not differ among UFF patients with or without a previous history of peritonitis. Peritoneal rest enabled patients with UFF to continue on PD for a median time of 23 months (range, 13 - 46 months). CONCLUSIONS: Peritoneal rest induces functional changes in patients with UFF but not in those with no functional abnormalities. This demonstrates that PR works only when abnormal but reversible functional conditions are present. However, the effect is highly dependent on how early PR is applied.

[Normal values of bioimpedance vector in Spanish population]. / Vectores de impedancia bioeléctrica de referencia para la población española.

BACKGROUND AND OBJECTIVE: The bioelectrical impedance vector analysis is useful for the determination of body composition in patients with altered hydration status. The original tolerance ellipses were made in Italian healthy individuals. Due to differences in body composition between populations, the aim of the study was to establish specific tolerance ellipses for the Spanish population and compare them with those ellipses made in the original reference population. METHODS: We studied 311 Spanish healthy subjects of both sexes, between 18 and 80 years old, with a BMI between 18 and 31 Kg/m², who underwent measurements of weight, height and bioelectrical impedance. The values of resistance and reactance standardized by height (R/H and Xc/H) derived from the impedance measurement, were used to determine the body composition and construct the specific tolerance ellipses for this population. RESULTS: The characteristics of body composition were different between sex and age groups. We plotted values of R/H and Xc/H of the Spanish population on the Italian tolerance ellipses finding that vectors were placed in left quadrants, indicating different body composition. We therefore built specific tolerance ellipses for Spanish population based on values of R/H and Xc/H. Spanish tolerance ellipses were statistically different from the Italian. CONCLUSIONS: The vectors of the Spanish population were different from those of the Italian, hence the importance of having a self-reference pattern.

Fundamento y objetivo: El análisis de vectores de impedancia es útil para la determinación de la composición corporal en pacientes con alteración del estado de hidratación. Las elipses de tolerancia originales fueron hechas en individuos sanos italianos. Debido a las diferencias en composición corporal entre poblaciones, el objetivo del estudio fue establecer elipses de tolerancia específicas para la población española y compararlas con las elipses realizadas en la población original de referencia. Material y método: Se estudiaron 311 sujetos sanos españoles de ambos sexos, entre 18 y 80 años, con IMC entre 18 y 31 Kg/m2, a los cuales se les realizaron mediciones de peso, estatura e impedancia bioeléctrica. Los valores de resistencia y reactancia estandarizadas por la estatura (R/E y Xc/E) derivados de la medición de impedancia, fueron utilizados para determinar la composición corporal y realizar las elipses de referencias específicas para dicha población. Resultados: Las características de composición corporal fueron diferentes entre sexos y grupo etario. Se graficaron los valores de R/E y Xc/E de la población española sobre las elipses de tolerancia italianas, encontrándose que los vectores se situaban en los cuadrantes izquierdos, indicando diferente composición corporal, por lo que se construyeron elipses de tolerancia específicas para la población española a partir de los valores de R/E y Xc/E. Las elipses de tolerancia españolas fueron estadísticamente diferentes a las italianas. Conclusiones: Los vectores de la población española fueron diferentes a los de la población italiana, de ahí la importancia de tener un patrón de referencia propio.

Pretransplant peritoneal dialysis relative to hemodialysis improves long-term survival of kidney transplant patients: a single-center observational study.

BACKGROUND: Kidney transplantation is the best option for the treatment of end-stage renal disease in terms of survival and quality of life. These results can be influenced by the pretransplant dialysis modality. The aim of this study was to evaluate whether the pretransplantation dialysis modality influences patient and allograft survival beyond 10 years and examine the potential risk factors associated with the outcomes. METHODS: We conducted an observational, retrospective, single-center clinical study that included 236 patients [118 undergoing peritoneal dialysis (PD) and 118 undergoing hemodialysis (HD)] who proceeded to transplantation during the period December 1990-2002. Donor and recipient data were collected from our hospital's clinical registries. The follow-up period extended to the patient's death, the loss of the allograft, or loss to follow-up. The end date of the study was set at March 2012. RESULTS: In the multivariate analysis, the long-term patient survival rate was higher for the PD group than for the HD group [HR = 2.62 (1.01-6.8); p = 0.04]; however, the allograft survival rate was not significantly different between the two groups [HR = 0.68 (0.41-1.10); p = 0.12]. CONCLUSION: Pretransplantation dialysis modality is associated with long-term patient survival, with outcomes favoring peritoneal dialysis over hemodialysis. However, the pretransplant dialysis modality does not influence long-term graft loss risk.