Gastrointestinal Disorders in Peritoneal Dialysis Patients.

BACKGROUND: Gastrointestinal (GI) disorders in peritoneal dialysis (PD) patients are relatively understudied in the literature, even though they have a serious impact in the morbidity parameters and the quality of life for this group of patients. Various diagnostic tools have been used, including instrumental methods and questionnaires, invariably validated in comparative studies. SUMMARY: The prevalence of GI disorders is very high in PD patients. Compared to the haemodialysis patients they present a higher prevalence of reflux, eating dysfunction, gastroesophageal reflux, intestinal obstruction or adhesions and abdominal hernia. They may be divided into Gastric disorders (Gastroesophageal reflux disease, pathological Gastric emptying, Dyspepsia, Helicobacter pylori infection, peptic ulcers) and Intestinal disorders (Peritonitis, Diverticulosis, Constipation). Key Messages: The current paper is a review of the literature involving GI disorders in PD patients. This special group of patients with a special role of the peritoneal cavity and the GI motility in the physiology of their dialysis merit a larger number of studies dealing with the interrelation of the GI tract and the PD physiological, functional and pathophysiological parameters.

Vitamins in dialysis: who, when and how much?

Despite the significant technical evolution of the blood purification methods, cardiovascular morbidity and mortality in dialysis patients is still several times higher than that observed in the general population. Vitamins are playing a crucial role in multiple key metabolic pathways. Due to multiple factors, dialysis patients present very often hypo- or hypervitaminosis for a broad range of vitamins. Dialysis in the context of renal replacement therapy is associated with a non-physiological potassium-sparing dietetic regime. Additionally, there is a non-selective intradialytic loss of micro- and macronutrients, deranged intracellular kinetics and gastrointestinal malabsorption due to uratemia. Frequent treatment with antibiotics due to infections associated with the acquired uremia-related immunosuppression may derange the vitamin-producing intestinal microflora. Certain agents prescribed in the context of renal failure or other conditions may reduce the absorption of vitamins from the gastrointestinal tract. These factors may deplete a dialysis patient from vitamins, especially the ones with antioxidant activity that may be associated with cardioprotective properties. In other cases, vitamins metabolized and excreted by the kidneys may be accumulated and exert toxic effects. The scope of this paper is to describe the main issues on vitamin therapy in dialysis patients in view of the ever contradictory opinions and practices.

Pulmonary hypertension in dialysis patients.

Pulmonary hypertension in end-stage renal disease patients is associated with significantly increased morbidity and mortality. The prevalence of pulmonary hypertension in dialysis patients is relatively high and varies in different studies from 17% to 49.53% depending on the mode of dialysis and other selection factors, such as the presence of other cardiovascular comorbidities. The etiopathogenic mechanisms that have been studied in relatively small studies mainly include arteriovenous fistula-induced increased cardiac output, which cannot be accomodated by, the spacious under normal conditions pulmonary circulation. Additionally, pulmonary vessels show signs of endothelial dysfunction, dysregulation of vascular tone due to an imbalance in vasoactive substances, and local as well as systemic inflammation. It is also believed that microbubbles escaping from the dialysis circuit can trigger vasoconstriction and vascular sclerosis. The non-specific therapeutic options that proved to be beneficial in pulmonary artery pressure reduction are endothelin inhibitors, phosphodiesterase inhibitor sildenafil, and vasodilatory prostaglandins in various forms. The specific modes of treatment are renal transplantation, size reduction or closure of high-flow arteriovenous fistulas, and transfer from hemodialysis to peritoneal dialysis-a modality that is associated with a lesser prevalence of pulmonary hypertension.

Trends in the relation between hyperglycemia correction and active Charcot neuroarthropathy: results from the EPICHAR study.

INTRODUCTION: The pathophysiology of Charcot neuroarthropathy (CN) remains unclear. There are a number of hypotheses but these are not exclusive. In its clinical presentation, this complication intersects with the semiology of diabetic-induced neuropathy, such as peripheral hypervascularization and the appearance of arteriovenous shunt. The EPICHAR study is as yet an unpublished cohort of people living with diabetes complicated by CN (in active or chronic phase). Based on the findings of the EPICHAR study, this study aimed to investigate whether a reduction in the rate of hyperglycemia accompanies the onset of an active phase of CN. RESEARCH DESIGN AND METHODS: Hemoglobin A1c (HbA1c) levels were assessed 3 months (M3) and 6 months (M6) before the diagnosis of active CN (M0). RESULTS: 103 patients living with diabetes and presenting active CN were included between January and December 2019 from the 31 centers participating in this study (30 in France and 1 in Belgium). The mean age of the participants was 60.2±12.2 years; the vast majority were men (71.8%) living with type 2 diabetes (75.5%). Mean HbA1c levels significantly declined between M6 (median 7.70; Q1, Q3: 7.00, 8.55) and M3 (median 7.65; Q1, Q3: 6.90, 8.50) (p=0.012), as well as between M6 and M0 (median 7.40; Q1, Q3: 6.50, 8.50) (p=0.014). No significant difference was found between M3 and M0 (p=0.072). CONCLUSIONS: A significant reduction in HbA1c levels seems to accompany the onset of the active phase of CN. TRIAL REGISTRATION NUMBER: NCM03744039.

A Retrospective Comparison of Patient and Pressure Injury Data at Two Time Points in a Regional Hospital in France.

BACKGROUND: Pressure injuries (PIs) are a significant problem for health care institutions. PURPOSE: A retrospective study of patient data was conducted at a semi-urban state hospital in France, aiming to evaluate the rate of PIs and variables that may influence PI prevalence and care at 2 different time points. METHODS: Patient demographic, clinical, PI and PI prevention, and care variables were retrieved from the charts of all patients on all wards (except pediatrics and obstetrics) on October 20, 2009, and on October 24, 2013-4 years apart. Qualitative data were compared between the 2 dates using a t-test for independent variables. The remaining variables were compared using Pearson's chi-square method. P < .05 was considered significant. RESULTS: No significant differences were noted in PI rates (19% for 2009 and 16% for 2013) or the timing of their occurrence (51% occurred following admission in 2009, and 58.3% occurred after admission in 2013). Significant differences were found with regard to patient age (average, 73.97 and 76.22 years old in 2009 and 2013, respectively; P = .014) and rates of serious injuries (27% and 43% were stages 3 and 4 in 2009 and 2013, respectively; P = .010). Compared with 2009, in 2013, significantly more patients were placed on a specialty mattress and provided nutritional supplements and fewer were provided percutaneous endoscopic gastrostomy or nasogastric tubes. CONCLUSION: The rate of PIs was not different between these 2 time points despite improvements in the use of preventive and therapeutic measures, perhaps due to the increased age and frailty of the patient population in 2013 compared with 2009. Additional prospective research across multiple health care entities is warranted.

Constipation in Peritoneal Dialysis Patients.

Constipation in peritoneal dialysis (PD) is an infrequent but potentially serious condition affecting the mechanical properties of dialysis techniques and predisposing to bacterial intestinal translocation and eventual enteric peritonitis. Despite the importance of the problem, published literature is scarce, consisting mostly of uncontrolled single-center trials. This inconsistency may be attributed to the large number of clinical, radiological, and endoscopic tools that have been used in the studies with a lack of generally accepted core primary outcomes.The current narrative review discusses the pathophysiological associations between chronic kidney disease, PD, and constipation with related complication.