Progressive demyelinating neuropathy after initiation of continuous ambulatory peritoneal dialysis--report of two cases

We report on two patients who developed rapidly progressive demyelinating neuropathy within 6 to 10 weeks after the initiation of continuous ambulatory peritoneal dialysis. The neuropathy in one patient resolved after kidney transplantation while that of the other patient improved with immunosuppressive therapy. The close temporal relationship between the initiation of peritoneal dialysis and the onset of neuropathy suggests that these two events may be causally related.

Relationship between adequacy of dialysis and nutritional status, and their impact on patient survival on CAPD in Hong Kong

OBJECTIVE

Superior patient survival on continuous ambulatory peritoneal dialysis (CAPD) with 3 x 2-L exchanges has been reported from Hong Kong. This study examined the relationship between indices of dialysis adequacy and nutrition and patient survival on CAPD in Hong Kong.

DESIGN

A cross-sectional study on prevalent CAPD patients. Patients were assessed for indices of dialysis adequacy and nutritional status with a composite nutritional index (CNI). Patients were then followed for 24 months. Survival data were analyzed according to adequacy indices and nutritional status.

SETTING

All prevalent CAPD patients in nine dialysis centers in Hong Kong as of 1 April 1996.

MAIN OUTCOME MEASURE

Mortality.

RESULTS

937 patients were assessed: 68.2% were using 3 x 2-L exchanges per day; mean age was 54.6 +/- 13 years. Mean total Kt/V was 1.83 +/- 0.42 and total creatinine clearance was 55.6 +/- 19.5 L/week/1.73 m2. 19% of patients were moderately to severely malnourished according to the CNI. There was no significant correlation between indices of adequacy and serum albumin or CNI. The 1- and 2-year patient survival from the time of assessment was 90.9% and 79.8%. There was a trend toward better survival in patients with Kt/V greater than 2.0, but it was not statistically significant. Peritoneal Kt/V did not impact survival in anuric patients. Malnourished patients had poorer survival than patients who were better nourished (p = 0.0259). After adjusting for age and diabetes, CNI was predictive of mortality but Kt/V and creatinine clearance were not.

CONCLUSIONS

This study demonstrates the importance of nutritional status over adequacy indices in predicting patient survival. There was a lack of correlation between nutritional status and conventional indices of dialysis adequacy.

Polymicrobial outbreak of intermittent peritoneal dialysis peritonitis during external wall renovation at a dialysis center

OBJECTIVE

To investigate an outbreak of peritonitis in intermittent peritoneal dialysis (IPD) patients.

DESIGN

An outbreak investigation was performed to identify the etiology of the polymicrobial outbreak, and a retrospective case-control study was conducted to assess the risk factors for development of peritonitis.

SETTING

Renal dialysis center.

PATIENTS

Ten episodes of peritonitis occurred in 8 of 61 patients over a 6-month period in which 669 IPD procedures were analyzed.

INTERVENTIONS

Field visit to renal dialysis center to examine the entire IPD procedure, inspect the hospital environment, and perform air bacterial count.

MAIN OUTCOME MEASURES

The environmental factors and risk factors contributing to the polymicrobial peritonitis outbreak in IPD patients. The incidence of IPD peritonitis was determined before and after interventions.

RESULTS

The causative organisms included Acinetobacter baumanii (6), Stenotrophomonas maltophilia (2), Pseudomonas aeruginosa (1), Candida albicans (1), C. tropicalis (1), Enterococcus (3), and Enterobacteriaceae (2). Four episodes of peritonitis involved infection by more than one organism. Air sampling of the environment detected a median of 110 colony forming units of bacteria per cubic meter of air, 10% of which were found to be Acinetobacter baumanii. The source of this polymicrobial outbreak was attributed to the bamboo scaffolding structure covering the external wall of the hospital during renovation. A retrospective case-control study indicated that the absence of the flush-before-fill step was a risk factor for development of peritonitis.

CONCLUSION

In addition to invasive aspergillosis in transplant or oncology patients, Acinetobacter peritonitis in dialysis patients should be considered another microbial cause of outbreak associated with hospital renovation.

Single dose diclofenac suppository reduces post-Cesarean PCEA requirements

PURPOSE

To assess the analgesic efficacy of administering, immediately after surgery, a single dose of diclofenac (100 mg suppository) to women who had undergone lower segment Cesarean section (LSCS) under combined spinal-epidural anesthesia, and received post-operative patient-controlled epidural analgesia (PCEA) with ropivacaine 0.2% and fentanyl 2 microg x ml(-1).

METHODS

Forty-eight ASA physical status I or II term parturients scheduled for elective LSCS under regional anesthesia were enrolled into this randomised double-blind study. The patient-controlled epidural analgesia device was programmed to deliver a bolus of 4 ml of local anesthetic mixture with a lockout period of ten minutes and an hourly limit of 12 ml. There was no baseline infusion. The study commenced upon the patient's first demand for analgesia post-operatively and the patients were assessed at one, six, 12 and 24 hr post-operatively for pain scores on movement, dermatomal level of sensory blockade, degree of motor blockade and volume of local anesthetic used. At conclusion of the study, patients' satisfaction scores were recorded.

RESULTS

The two groups of patients were similar demographically. Patients who received a diclofenac suppository used 52.8 +/- 17.8 ml of local anesthetic mixture while those who did not, used 74 +/- 25 ml (P <0.005). Pain scores and satisfaction scores did not differ significantly between the groups.

CONCLUSION

A single administration of 100 mg diclofenac suppository is effective in reducing post-Cesarean epidural local anesthetic/opioid requirements by 33% for the first 24 hr post-operatively.

Simultaneous removal and reinsertion of Tenckhoff catheters for the treatment of refractory exit-site infection

Exit-site infection (ESI) refractory to medical therapy is an important complication of continuous ambulatory peritoneal dialysis (CAPD). Between July 1994 and June 1998, 28 patients in our hospital underwent simultaneous removal and reinsertion of Tenckhoff catheters for the treatment of refractory ESI. The ESI was caused by Pseudomonas aeruginosa in 22 patients (78%), methicillin-resistant Staphylococcus aureus in 5 patients (18%), and diphtheroid bacilli in 1 patient (4%). The patients had received antibiotic treatment for a mean duration of 11.6 +/- 5.8 weeks (range: 3-28 weeks) before their operations. During each operation, the old Tenckhoff catheter was removed and a new catheter was inserted in the opposite side of the abdomen. CAPD was resumed after two weeks of intermittent peritoneal dialysis. All patients received intravenous antibiotic cover for seven days after the operation. Early post-operative complications were uncommon. At one year after the operation, 22 patients (78%) were free of ESI. Six patients (22%) had a recurrence of ESI 21.3 +/- 6 weeks (range: 16-32 weeks) after their operation. All new infections were treated successfully with antibiotics. Seven patients (25%) had one episode of peritonitis each, all of which resolved with intraperitoneal antibiotic treatment. We conclude that simultaneous removal and reinsertion of Tenckhoff catheters is a safe and effective method for the treatment of refractory ESI. The procedure alleviates the need for temporary hemodialysis and allows an early return to CAPD.

Lenses of SPARC-null mice exhibit an abnormal cell surface-basement membrane interface

SPARC (secreted protein acidic and rich in cysteine) is a matricellular protein involved in cell-matrix interactions. We have shown previously that mice deficient in SPARC develop posterior cortical cataract early in life that progresses to a mature opacity and capsule rupture. To evaluate the primary effects of SPARC deficiency in the lens, we examined the lenses of SPARC-null and wild-type mice by electron microscopy and immunohistochemistry to investigate whether ultrastructural abnormalities occur at the basement membrane (capsule)-lens cell interface in SPARC-null mice. The most notable feature in the lenses of SPARC-null mice, relative to wild-type animals, was the modification of the basal surface of the lens epithelial and fiber cells at the basement membrane (capsule) interface. Electron microscopy revealed numerous filopodial projections of the basal surface of the lens epithelial and fiber cells into the extracellular matrix of the anterior, posterior, and equatorial regions of the lens capsule. In 1 week old precataractous lenses, basal invasive filopodia projecting into the capsule were small and infrequent. Both the size and frequency of these filopodia increased in precataractous 3-4 week old lenses and were prominent in the cataractous 5-6 week old lenses. By rhodamine-phalloidin labeling, we confirmed the presence of basal invasive filopodia projecting into the lens capsule and demonstrated that the projections contained actin filaments. In contrast to the obvious abnormal projections at the interface between the basal surface of the lens epithelial and fiber cells and the lens capsule, the apical and lateral plasma membranes of lens epithelial cells and lens fibers in SPARC-null mice were as smooth as those of wild-type mice. We conclude that the absence of SPARC in the murine lens is associated with a filopodial protrusion of the basal surface of the lens epithelium and differentiating fiber cells into the lens capsule. The altered structures appear prior to the opacification of the lens in the SPARC-null model. These observations are consistent with one or more functions previously proposed for SPARC as a modulator of cell shape and cell-matrix interactions.

Spatiotemporal distribution of zonulae adherens and associated actin bundles in both epithelium and fiber cells during chicken lens development

Zonulae adherens and associated actin bundles (ZA/AB) are believed to play a major role in epithelial folding and invagination during morphogenesis of neural tube and other vesicular structures. The lens morphogenesis is associated with the formation of the lens vesicle in which ZA/AB would be needed during the formation process. However, the existence of ZA/AB in the lens has never been established. In this study we report for the first time the existence of ZA/AB in both lens epithelium and fiber cells during embryonic development of chicken lens from E4 to E20. Light microscopy revealed contacts between the lens epithelium and primary fiber cells, and between the lens epithelium and secondary fiber cells at E4 and E11, respectively. Thin-section electron microscopy consistently revealed ZA/AB near both the apical ends of lens epithelial cells and primary fiber cells at E4. This arrangement manifests as a parallel pair of belt-like ZA/AB along the epithelium-fiber interface. In semi-tangential sections, a continuous belt-like ZA/AB was also evidenced in individual epithelial cells and fiber cells. Furthermore, the same ZA/AB arrangement was observed near both the apical ends of epithelial cells and secondary fiber cells at E11. Besides ZA/AB, macular-type fasciae adherens were distributed regularly between epithelial cells, between primary fibers, between secondary fibers, and between epithelium and both primary and secondary fibers. Immunofluorescence strongly and preferentially labeled N-cadherin at both the apical ends of lens epithelium and primary or secondary fibers at the corresponding ages, suggesting a direct association with the zonulae adherens. Also punctate N-cadherin labeling was commonly seen along various regions of primary and secondary fiber cells at different ages, and to a larger extent in the mature fibers of older lenses. This study suggests that: (1) ZA/AB located at the apices of lens epithelial cells may play a crucial role in the early stages of lens morphogenesis (e.g. lens vesicle formation); (2) ZA/AB of primary and secondary fiber cells originate from the epithelial cells during their elongation and differentiation; (3) owing to the restricted distribution of ZA/AB, abundant fasciae adherens are needed to maintain the structural stability of the epithelium and fiber cells during development and maturation; and (4) N-cadherin is the principle adhesion protein for both the zonulae adherens and fasciae adherens in the lens.

Loss of heterozygosity at the short arm of chromosome 3 in microdissected cervical intraepithelial neoplasia

Loss of heterozygosity (LOH) is a common genetic finding in many human neoplasms, including cervical cancer. The detection of LOH at specific loci in the precursor of cervical cancer, cervical intraepithelial neoplasia (CIN) may help in elucidating the evolution of this cancer, which has a clearly defined histological premalignant phase. However, molecular genetic investigation of CIN is difficult because many of the lesions are very small and sometimes ill defined topographically. In this study we analyzed eighteen polymorphic microsatellite repeats on chromosome 3p in CINs using a method of primer extension pre-amplification (PEP) for whole genome amplification combined with microdissection. These markers encompass chromosome region 3pter-3p12. LOH at one or more loci was detected in five (33%) out of the 15 informative cases with low grade CIN (CIN 1), while 22 (92%) out of 24 cases with high grade CIN (CIN 2 and 3) (P<0.01). The highest incidence (41%) of LOH was detected at locus D3S1038 (3p26.1-3p25.2). Frequent LOH (more than 20%) was also found at other loci including D3S1110 (3p25.3-3p25.1) (31%), D3S656 (3p25.1) (24%), D3S1076 (3p21.2-3p21.1) (29%), D3S1300 (3p21.1-3p14.2) (24%), D3S1600 (3p14.2-3p14.1) (24%), and D3S1079 (3p13) (25%). The results from this study taken together with others indicate that the genetic alterations on chromosome 3p are common in high grade of CIN and are probably early events in cervical carcinogenesis. Tumor suppressor gene(s) that play a role in cervical neoplasm may be located on the short arm of chromosome 3, likely at or near 3p26.1-25.1, 3p21.2-21.1, and 3p14.2-13.

Lim2(To3) transgenic mice establish a causative relationship between the mutation identified in the lim2 gene and cataractogenesis in the To3 mouse mutant

PURPOSE

Lim2 is the gene encoding the ocular lens-specific intrinsic membrane protein MP19. We previously reported finding a single nonconservative G->T transversion in exon two of the Lim2 gene. This mutation was linked to the cataract in the To3 (Total opacity number 3) mouse mutant, confirming Lim2 as an ideal candidate gene for the To3 cataract. The aim of the present study was to substantiate a causative relationship between the mutation in the Lim2 gene and cataractogenesis in the To3 mouse mutant. To this end a Lim2To3 transgene cassette was engineered and introduced into fertilized normal mouse embryos to test its ability to induce cataractogenic lens development.

METHODS

A Lim2 genomic clone was isolated and purified from a murine 129/SvJ genomic library. A restriction endonuclease map of the gene was generated using classical Southern techniques. The murine Lim2 promoter was characterized by transfecting primary chicken lens epithelial cells with Lim2 promoter-CAT reporter constructs and assaying promoter activity and specificity. This genomic clone was then used in conjunction with PCR to generate a Lim2To3 transgene cassette. After sequencing of the PCR engineered portion, the Lim2To3 transgene was then used to generate Lim2To3 transgenic mice via pronuclear injection. Founder mice and their offspring from outcrosses and intercrosses were characterized by ophthalmic examination, PCR and Southern DNA analysis, RT-PCR mRNA analysis, and histology of lens sections.

RESULTS

Two mice, from independent microinjections, were identified as positive for presence of the Lim2To3 transgene cassette as well as presence of bilateral congenital cataracts and reduced eye size and mass. One of these founders was incapable of germline transmission of the transgene to offspring and was not characterized further. The other was capable of germline transmission and was characterized as described above. PCR DNA analysis revealed a perfect concordance between presence of the Lim2To3 transgene cassette and congenital cataract in offspring of this founder. Transgenic hemizygotes exhibited cataract and a reduction in eye and lens size and mass, while transgenic "homozygotes" presented with a more severe cataract and microphthalmic reduction in eye and lens size and mass. Southern analysis revealed approximately 2 copies of the transgene cassette integrated into a single chromosomal site in the founder and all hemizygous offspring. RT-PCR analysis revealed a very low ratio of Lim2To3 transgenic mRNA compared to endogenous normal Lim2. Finally, histology revealed that lens development was abnormal in mutant transgenic animals by embryonic day E15. By E19, just prior to birth, gross disorganization of secondary fibers was observed in mutants.

CONCLUSIONS

These transgenic experiments firmly establish a causative relationship between the previously identified mutation in the Lim2 gene and cataractogenesis in the To3 mouse mutant. The low levels of mutant mRNA produced by the transgene cassette as compared to endogenous levels of normal Lim2 mRNA provides evidence that this dominant mutation results in a mutant MP19 protein with altered function rather than simply loss of function.

A randomised double-blind placebo-controlled trial of transcervical intrauterine local anaesthesia in outpatient hysteroscopy

OBJECTIVE

To assess whether transcervical intrauterine instillation of local anaesthetic agent reduces pain during diagnostic outpatient hysteroscopy and endometrial biopsy.

DESIGN

Prospective, randomised, double blind, placebo-controlled trial.

SETTING

Outpatient hysteroscopy clinic in a university teaching hospital.

POPULATION

Ninety women undergoing outpatient diagnostic hysteroscopy with or without endometrial biopsy.

METHODS

Transcervical intrauterine instillation of 5 mL of 2% lignocaine into the uterine cavity before performing the procedure.

MAIN OUTCOME MEASURES

Evaluation of pain at different stages of the procedure using a visual analogue scale and changes in blood pressure and heart rate.

RESULTS

The use of local anaesthetic did not alleviate pain experienced during hysteroscopy and endometrial biopsy. It did not prevent the occurrence of vaso-vagal reactions; however the incidence of these was low.

CONCLUSIONS

Transcervical instillation of local anaesthesia neither reduced pain nor prevented vaso-vagal reaction during hysteroscopy and endometrial biopsy.

Use of hyperbaric oxygen therapy in Hong Kong

The Recompression Treatment Centre on Stonecutters Island has been operating in Hong Kong for more than 5 years and has been used to treat a variety of diving-related and other conditions by means of hyperbaric oxygen therapy. Up to the end of December 1997, 295 treatment sessions had been conducted for 39 patients. This article reviews the usefulness of and indications for hyperbaric oxygen therapy.

A comparison of patient-controlled epidural analgesia following gynaecological surgery with and without a background infusion

We conducted a randomised, controlled study to investigate the effect of adding a background infusion to patient-controlled epidural analgesia for postoperative pain relief. Forty-two patients scheduled for elective lower abdominal gynaecological surgery received patient-controlled epidural analgesia postoperatively using a mixture of 0.2% ropivacaine and 2.0 microg x ml-1 fentanyl. Patients in group B (n = 20) were given a background infusion of 5 ml x h-1, whereas those in group N (n = 21) were not. There was no difference in pain scores or patient satisfaction scores between the two groups. Patients in group B had a higher total drug consumption (156.8 +/- 34.8 ml vs. 89.5 +/- 41.0 ml; p < 0.0001) and incidence of side-effects (71.4% vs. 30.0%; p = 0.007). Motor blockade during the 24-h study period was also greater in group B (median [range] area under the curve 7.5 [0.0-39.0] h vs. 3.0 [0.0-36.0] h; p = 0.035). We conclude that the addition of a background infusion to patient-controlled epidural anaesthesia is not recommended as it confers no additional benefits.

Combined spinal epidural for labour analgesia--duration, efficacy and side effects of adding sufentanil or fentanyl to bupivacaine intrathecally vs plain bupivacaine

AIM OF STUDY

The aim of the study was to evaluate the efficacy and side effects of adding sufentanil 10 micrograms, fentanyl 10 micrograms or a control of 1 mL saline to 2.5 mg bupivacaine given intrathecally via combined spinal epidural (CSE) for labour pain relief in the first stage.

METHOD

Sixty ASA I or II patients who requested for epidural analgesia were randomised to three groups. CSE was performed with a 16G Touhy needle and 27G Whitacre needle.

RESULTS

Patients in the sufentanil/bupivacaine group had a significantly longer duration of analgesia (162.9 min +/- 63.4) compared with fentanyl/bupivacaine (110.0 min +/- 44.6) compared with plain bupivacaine (70.0 min +/- 32.1). Pruritus was significant in patients with sufentanil (80%) and fentanyl (47.4%) but did not occur with plain bupivacaine. There was no significant difference in the incidence of nausea or vomiting, hypotension and motor blockade although blood pressures in the sufentanil group were consistently lower than the other two groups. Pain scores were lowest in the sufentanil group. Fetal heart rate changes and Apgar scores were not significantly different between the groups.

CONCLUSION

In combined spinal epidural for labour analgesia, adding sufentanil 10 micrograms to intrathecal bupivacaine 2.5 mg provided fast onset and good analgesia for a longer duration compared with adding fentanyl 10 micrograms and with plain bupivacaine. The main side effect was pruritus. Neonatal outcome was similar.

Optimal peritoneal dialysis for patients from Hong Kong

The socioeconomic statuses of Asian countries are diverse and government reimbursement policies for renal replacement programs vary greatly from one country to another. Both factors affect not only the availability of treatment but also the choice of dialysis modality. Despite the economic growth of Hong Kong over the past three decades, the resources spent by our government on health services are less than other developed countries. The National Health Service, which is run on a tight budget, supports almost 95% of the patients on renal replacement programs. Due to the cost-effectiveness and reimbursement from the government, 79% of patients with end-stage renal failure in Hong Kong are treated with continuous ambulatory peritoneal dialysis (CAPD). All new patients entering the renal replacement program run by the National Health Service are offered CAPD as the first-line dialytic treatment. Due to budgetary constraint, over the past 10 years dialysis centers in Hong Kong have adopted a small-volume regime of 3 x 2-L daily exchanges as the initial dialysis prescription. This dialysis prescription will be considered to be suboptimal by Western standards, but the survival of these patients was comparable to, or even better than, other areas despite a lower Kt/V. These preliminary studies suggest small-volume dialysis may be an acceptable compromise in Asian populations with their smaller body size, given the financial constraints. These issues are especially important in Asia, where financial resources for renal replacement therapy are still limited in most countries and many patients have to continue working to pay for their renal replacement treatment. Using this small-volume dialytic regime, more patients may be treated with the limited financial resources. Furthermore, our experience raises the question of the importance of nutritional status in patient survival.

Paracervical anaesthesia in outpatient hysteroscopy: a randomised double-blind placebo-controlled trial

OBJECTIVE

To evaluate the efficacy and safety of paracervical anaesthesia in reducing pain during outpatient hysteroscopy and endometrial biopsy.

DESIGN

Prospective, randomised, placebo-controlled, double-blind study.

POPULATION

One hundred women undergoing outpatient hysteroscopy and endometrial biopsy for abnormal uterine bleeding.

INTERVENTIONS

Paracervical block using 10 mL of either 2% lignocaine or normal saline before the procedure.

MAIN OUTCOME MEASURES

Evaluation of pain at different stages of hysteroscopy using a visual analogue scale together with blood pressure and heart rate monitoring.

RESULTS

Compared with placebo, paracervical anaesthesia significantly reduced the pain only at the time of insertion of the hysteroscope, but not at the subsequent stages of the procedure. However, paracervical injection of lignocaine resulted in a higher incidence of bradycardia and hypotension.

CONCLUSIONS

Paracervical anaesthesia not only fails to reduce pain during outpatient hysteroscopy and endometrial biopsy, but also carries a risk of inducing bradycardia and hypotension, which is probably a result of inadvertent intravascular injection.

Long-term renal allograft recipients from South-east Asia in the pre-cyclosporin era

The clinical outcome of long-term renal allograft recipients in the Chinese population has not been reported previously. We analysed patients from the pre-cyclosporin era who had grafts that functioned for > 10 years. Forty-five patients (31 men, 14 women; mean age 30, follow-up duration 13.3 years), representing a 10-year graft survival of 53%, were included. Thirty-six patients (80%) received living-related allografts and 9 (20%) received cadaveric or living-unrelated renal transplantation. The mean serum creatinine at last follow-up was 1.36 mg/dl (range, 0.83-4.08). Major posttransplantation complications included: hypertension in 25 (56%), infection in 16 (36%), acute rejection in 15 (33%), lipid disorder in 13 (29%), liver disease in 7 (16%), osteonecrosis in 5 (11%), malignancy in 4 (9%), coronary artery disease in 3 (7%), and diabetes mellitus in 3 (7%). Five grafts were lost: 3 to chronic rejection, and 2 to patients with stable function who died of non-renal causes. Proteinuria correlated strongly with graft function and survival, and marginally with hypertension. In hepatitis B carriers, serum alpha-feto protein is useful in the early detection of hepatocellular carcinoma. We conclude that while patients in the pre-cyclosporin era can survive with excellent graft function beyond the first decade, the risk of complications leading to significant morbidity still remains even when patients are receiving minimal doses of immunosuppression in the second decade.

Benefits of exercise training in patients on continuous ambulatory peritoneal dialysis

We examined the effects of a 12-week exercise program on the exercise tolerance, blood biochemistry, blood pressure (BP) control, cardiac function, and quality-of-life (QOL) scores in 13 patients undergoing continuous ambulatory peritoneal dialysis (CAPD; six men, seven women; mean age, 46.5+/-12.8 years; mean duration on dialysis, 4.8+/-3.8 years). The patients underwent exercise training on treadmill, bike, and arm ergometers thrice weekly. Seven CAPD patients matched for age, sex, and duration on dialysis served as controls. The mean peak aerobic capacity (VO2peak) of the exercisers increased by 16.2% after training (pre- and postexercise, 17.2+/-5.2 v 20.0+/-6.4 mL/kg/min; P=0.004). Although there were no significant changes in serum urea, creatinine, albumin, and hematocrit levels; left ventricular diastolic/systolic diameters; and ejection fraction, an increasing trend of high-density lipoproteins (HDLs) was observed in the exercisers (baseline v postexercise, 33+/-11 v 40+/-14 mg/dL; P=0.06). Twenty-four-hour ambulatory BP monitoring showed a significant increase in daytime systolic BP in the exercisers (pre- and postexercise, 142+/-26 v 157+/-22 mm Hg; P=0.003), but no significant changes could be found in the ambulatory daytime diastolic BP, nocturnal BP, and resting clinic BP. The patients' QOL improved after training, with better scores in two Kidney Disease Quality of Life scales (KDQOL): burden of kidney disease and physical functioning. Two mild and uncomplicated hypotensive episodes were reported in two patients immediately after training. No changes occurred in exercise capacity, blood biochemistry, BP profile, and QOL scores in the controls. We conclude that structured aerobic exercise is safe and can improve the exercise tolerance and QOL outcomes in CAPD patients.