The role of APD in the improvement of outcomes in an ESRD program

Efficacy of APD in perioperative period of non-abdominal operation for peritoneal dialysis patients

Objectives: Whether automated peritoneal dialysis (APD) is a feasible strategy in perioperative period of uremic patients undergoing nonabdominal surgery remains unclear. This study was conducted to research the perioperative management and the best choice of dialysis modalities for peritoneal dialysis patients.

Materials and methods: A retrospective analysis was made on the clinical data of 58 ESRD patients who had received peritoneal dialysis for more than three months were treated with APD during perioperative period from July 2015 to March 2018 in the Second Affiliated Hospital of Soochow University. The differences of clinical parameters, such as urine volume, ultrafiltration volume, hemoglobin, renal function and electrolytes were collected and analyzed before and after APD.

Results: The vital signs of 58 patients were stable after APD treatment, and there were no significant differences in 24-hour urine volume, hemoglobin and electrolytes (calcium, phosphorus, potassium, sodium) before and after surgery (P>0.05). Compared with those before treatment, the amount of ultrafiltration increased significantly (P<0.05), creatinine, urea nitrogen and parathyroid hormone decreased significantly (P<0.05), while albumin decreased (P<0.05).

Conclusion: Application of APD for peritoneal dialysis patients undergoing nonabdominal surgery during the perioperative period is safe and effective.

Age is not a contraindication to home-based dialysis - Quality-of-Life outcomes favour older patients on peritoneal dialysis regimes relative to younger patients

AIM

To compare Quality of Life, anxiety and depression between older (≥65 years) and younger (<65 years) patients across automated peritoneal dialysis and continuous ambulatory peritoneal dialysis.

BACKGROUND

There is a lack of studies as to whether the different peritoneal dialysis modalities confer similar outcomes in older and younger patients.

DESIGN

Cross-sectional.

METHODS

A total of 201 patients completed the Kidney Disease Quality of Life Short-Form, World Health Organization Quality of Life Instrument, Short Form and Hospital Anxiety and Depression Scale. Comorbidity and biochemical values were abstracted from medical records.

RESULTS

Older patients reported significantly better quality of life than younger patients in the Kidney Disease Quality of Life Short-Form effects of kidney disease and patient satisfaction and the World Health Organization Quality of Life Instrument overall Quality-of-Life/health despite worse clinical profile. Quality of life outcomes were comparable between automated peritoneal dialysis and continuous ambulatory peritoneal dialysis with the exception of the Kidney Disease Quality of Life Short-Form symptoms in favour of automated peritoneal dialysis. Levels of anxiety and depression were equivalent for older and younger patients across peritoneal dialysis modalities. The observed quality-of-life advantages for older patients persisted after case-mix adjustments and extended to more quality-of-life domains and depression and anxiety.

CONCLUSION

Our findings of superior quality of life in patients aged ≥ 65 support the expansion of peritoneal dialysis use in older patients. Patients across different age groups should be given non-biased information about both peritoneal dialysis modalities and individual preferences should be elicited and carefully considered by healthcare providers.

Assessment of health-related quality of life: the cinderella of peritoneal dialysis?

The studies of quality of life (QoL) are becoming increasingly interesting in clinical setting because their findings have implications for making decisions on resource allocation and health policies. The assessment of health-related QoL is especially directed to patients with chronic illnesses that cause progressive deterioration and limitations, and consume the bulk of financial resources for health. Among these chronic kidney disease and, more specifically the renal replacement therapy, is an important condition. Due to the diagnostic and therapeutic advances, we see a gradual increase both in the number of the dialysis population and its age, which leads to a growing interest in the study of these patients' QoL, as evidenced by more than one thousand articles published on this subject.

Concentration of adipokines in peritoneal effluent: a new marker of acute peritonitis in peritoneal dialysis patients?

BACKGROUND

An early and reliable diagnostic procedure for acute peritonitis in patients on peritoneal dialysis (PD) without typical clinical symptoms remains an important challenge in modern nephrology. During the first days of peritonitis, establishing the diagnosis based on peritoneal effluent pleocytosis and inflammatory markers [C-reactive protein (CRP) or interleukin-6] is not efficient in all cases. Increased peritoneal membrane permeability is a well-known consequence of peritonitis. Therefore, we evaluated the concentrations of selected circulating adipose tissue-derived proteins in the peritoneal effluent of PD patients with episodes of acute peritonitis.

MATERIAL AND METHODS

Concentrations of adiponectin and leptin, in both plasma and peritoneal effluent, were assessed in 24 adult PD patients with peritonitis episodes confirmed by clinical symptoms and/or microbiological tests, and in 23 PD patients without signs and symptoms of inflammation (control group).

RESULTS

In peritoneal effluent collected from patients with acute peritonitis (also without pleocytosis or increased CRP), both adiponectin and leptin concentrations were markedly elevated: adiponectin 744.1 (344.2 - 1144.1) ng/mL vs 4.8 (3.1 - 6.5) ng/mL; leptin 16.3 (9.4 - 23.1) ng/mL vs 5.1 (0.5 - 9.6) ng/mL. Receiver operating characteristic analyses revealed that peritoneal effluent adiponectin concentration >180 ng/mL has 100% sensitivity and 100% specificity, while peritoneal effluent leptin concentration >11.0 ng/mL has 58.3% sensitivity and 95.5% specificity for the diagnosis of acute peritonitis. The increases in adiponectin and leptin concentrations in peritoneal effluent were not consequences of changes in their plasma levels. A positive correlation between peritoneal effluent and plasma concentrations of adiponectin and leptin in patients with peritonitis was found.

CONCLUSION

Increased concentration of leptin and especially adiponectin in peritoneal effluent seems to be a valuable and new early marker of high peritoneal membrane permeability due to acute peritonitis.

The importance of residual renal function in dialysis patients

Preserving residual renal function has always been the primary clinical goal for every nephrologist managing patients with chronic kidney disease. There is no reason why this important goal should not extend to patients with stage 5 chronic kidney disease receiving dialysis. Indeed, there is now clear evidence that preserving residual renal function remains important after the commencement of dialysis. Residual renal function contributes significantly to the overall health and well-being of dialysis patients. It not only provides small solute clearance but also plays an important role in maintaining fluid balance, phosphorus control, and removal of middle molecular uremic toxins, and shows strong inverse relationships with valvular calcification and cardiac hypertrophy in dialysis patients. Decline of residual renal function also contributes significantly to anemia, inflammation, and malnutrition in patients on dialysis. More importantly, the loss of residual renal function, especially in patients on peritoneal dialysis, is a powerful predictor of mortality. In addition, there is increasing evidence that residual renal and peritoneal dialysis clearance cannot be assumed to be equivalent qualitatively, thus indicating the need to preserve residual renal function in patients on dialysis. In this article, we will review evidence that residual renal function is important in dialysis patients (especially peritoneal dialysis) and outline potential strategies that may better preserve residual renal function in dialysis patients.

Residual renal function: considerations on its importance and preservation in dialysis patients

Residual renal function (RRF) remains important even after commencement of dialysis. Its role in the adequacy of peritoneal dialysis (PD) is well recognized and is increasingly utilized in incremental PD regimes, but it is also vitally important in hemodialysis (HD) patients, in whom it, as in PD patients, may improve survival. It may allow for a reduction in the duration of HD sessions. It reduces the need for dietary and fluid restrictions in both PD and HD patients. Other contributions include improved middle molecule clearance, better hemoglobin, phosphate, potassium, and urate levels, enhanced nutritional status and quality of life scores, and better outcomes in pregnancy. On the negative side, hypoalbuminemia may be prolonged in patients with persistent nephrotic-range proteinuria. Contrary to popular belief, RRF does not necessarily decline rapidly with the initiation of HD. PD may be better than HD in preserving RRF, although this difference may not persist if biocompatible membranes, bicarbonate buffer, and ultrapure water are used. Nocturnal ambulatory peritoneal dialysis (APD) patients may fare worse than continuous ambulatory peritoneal dialysis (CAPD) patients. RRF can be adversely affected by angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), aminoglycosides, and radiocontrast agents. Diuretics can help maintain fluid balance but not RRF.