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Guo J, Liu R, Peng Y, Yi C, Wu H, Ye H, Lin J, Diao X, Huang F, Mao H, Guo Q, Yang X. The centre-calculated cutoff value is better for identifying fast peritoneal solute transfer of patients on peritoneal dialysis than the traditional value: a retrospective cohort study. Clin Kidney J 2023; 16:2023-2031. [PMID: 37915941 PMCID: PMC10616441 DOI: 10.1093/ckj/sfad197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Indexed: 11/03/2023] Open
Abstract
Background The mean 4-h dialysate to plasma ratio of creatinine (4-h D/Pcr) is a vital cutoff value for recognizing the fast peritoneal solute transfer rate (PSTR) in patients on peritoneal dialysis (PD); however, it shows a noticeable centre effect. We aimed to investigate our centre-calculated cutoff value (CCV) of 4-h D/Pcr and compare it with the traditional cutoff value (TCV) (0.65). Methods In this study, we enrolled incident PD patients at our centre from 2008 to 2019, and divided them into fast or non-fast PSTR groups according to baseline 4-h D/Pcr-based CCV or TCV. We compared the efficiency of the fast PSTR recognized by two cutoff values in predicting mortality, ultrafiltration (UF) insufficiency and technical survival. Results In total, 1905 patients were enrolled, with a mean 4-h D/Pcr of 0.71 ± 0.11. Compared with TCV (0.65), CCV (0.71) showed superiority in predicting mortality of PD patients [hazard ratio (HR) 1.27, 95% confidence interval (CI) 1.02-1.59 vs HR 1.24, 95% CI 0.97-1.59]. The odds ratio (OR) of the fast PSTR in centre classification was slightly higher than traditional classification in predicting UF insufficiency (OR 1.67, 95% CI 1.25-2.24 vs OR 1.60, 95% CI 1.15-2.22). Additionally, the restricted cubic splines 4-h D/Pcr has an S-shaped association with mortality and UF insufficiency, and the inflection points of 4-h D/Pcr were 0.71 (equal to CCV). Conclusions The CCV of 4-h D/Pcr for identifying fast PSTR was 0.71. It was superior to TCV in predicting mortality and UF insufficiency.
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Affiliation(s)
- Jing Guo
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Ruihua Liu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Yuan Peng
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Chunyan Yi
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Haishan Wu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Hongjian Ye
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Jianxiong Lin
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Xiangwen Diao
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Fengxian Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Haiping Mao
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Qunying Guo
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
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Malho Guedes A, Calças Marques R, Ribeiro B, Fernandes MT, Faísca M, Silva AP, Bragança J, Rodrigues A. Peritoneal Protein Loss, Inflammation, and Nutrition: Refuting Myths. Front Med (Lausanne) 2022; 9. [DOI: https:/doi.org/10.3389/fmed.2022.884061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Peritoneal protein loss (PPL) has been correlated with mortality, malnutrition and inflammation. More recently overhydration was brought to the equation. This study aims to review classic and recent factors associated with PPL. Prevalent and incident peritoneal dialysis (PD) patients were included. Dialysate and serum IL-6 was obtained during PET. Hydration and nutritional status were assessed by bio-impedance. Linear regression and Cox regression were performed. The 78 included patients presented median values of PPL 4.8 g/24 h, serum IL-6: 5.1 pg/mL, and IL-6 appearance rate 153.5 pg/min. Mean extracellular water excess (EWexc) was 0.88 ± 0.94 L, and lean body mass index (LBMI) 17.3 ± 2.4 kg/m2. After mean follow-up of 33.9 ± 29.3 months, 12 patients died. Linear univariable analysis showed positive associations between PPL and small solute transport, body composition (LBMI and EWexc), comorbidities and performing CAPD (vs. cycler). PPL correlated positively with dialysate appearance rate of IL-6, but not with serum IL-6. Linear multivariable analysis confirmed positive association between PPL and EWexc (p = 0.012; 95%CI: 4.162–31.854), LBMI (p = 0.008; 95%CI: 1.720–11.219) and performing CAPD (p = 0.023; 95%CI: 4.375–54.190). In survival analysis, no relationship was found between mortality and PPL. Multivariable Cox regression showed Charlson Comorbidity Index (HR: 1.896, 95%CI: 1.235–2.913), overhydration (HR: 10.034, 95%CI: 1.426–70.587) and lower PPL (HR: 0.576, 95%CI: 0.339–0.978) were predictors for mortality. Overhydration, was a strong predictor of PPL, overpowering variables previously reported as determinants of PPL, namely clinical correlates of endothelial dysfunction or local inflammation. PPL were not associated with malnutrition or higher mortality, emphasizing the importance of volume overload control in PD patients.
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Malho Guedes A, Calças Marques R, Ribeiro B, Fernandes MT, Faísca M, Silva AP, Bragança J, Rodrigues A. Peritoneal Protein Loss, Inflammation, and Nutrition: Refuting Myths. Front Med (Lausanne) 2022; 9:884061. [PMID: 35692552 PMCID: PMC9178188 DOI: 10.3389/fmed.2022.884061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022] Open
Abstract
Peritoneal protein loss (PPL) has been correlated with mortality, malnutrition and inflammation. More recently overhydration was brought to the equation. This study aims to review classic and recent factors associated with PPL. Prevalent and incident peritoneal dialysis (PD) patients were included. Dialysate and serum IL-6 was obtained during PET. Hydration and nutritional status were assessed by bio-impedance. Linear regression and Cox regression were performed. The 78 included patients presented median values of PPL 4.8 g/24 h, serum IL-6: 5.1 pg/mL, and IL-6 appearance rate 153.5 pg/min. Mean extracellular water excess (EWexc) was 0.88 ± 0.94 L, and lean body mass index (LBMI) 17.3 ± 2.4 kg/m2. After mean follow-up of 33.9 ± 29.3 months, 12 patients died. Linear univariable analysis showed positive associations between PPL and small solute transport, body composition (LBMI and EWexc), comorbidities and performing CAPD (vs. cycler). PPL correlated positively with dialysate appearance rate of IL-6, but not with serum IL-6. Linear multivariable analysis confirmed positive association between PPL and EWexc (p = 0.012; 95%CI: 4.162-31.854), LBMI (p = 0.008; 95%CI: 1.720-11.219) and performing CAPD (p = 0.023; 95%CI: 4.375-54.190). In survival analysis, no relationship was found between mortality and PPL. Multivariable Cox regression showed Charlson Comorbidity Index (HR: 1.896, 95%CI: 1.235-2.913), overhydration (HR: 10.034, 95%CI: 1.426-70.587) and lower PPL (HR: 0.576, 95%CI: 0.339-0.978) were predictors for mortality. Overhydration, was a strong predictor of PPL, overpowering variables previously reported as determinants of PPL, namely clinical correlates of endothelial dysfunction or local inflammation. PPL were not associated with malnutrition or higher mortality, emphasizing the importance of volume overload control in PD patients.
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Affiliation(s)
- Anabela Malho Guedes
- Serviço de Nefrologia, Centro Hospitalar Universitário do Algarve, Faro, Portugal
- Faculdade de Medicina e Ciências Biomédicas, Universidade do Algarve, Faro, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | | | - Brigitte Ribeiro
- Faculdade de Medicina e Ciências Biomédicas, Universidade do Algarve, Faro, Portugal
| | - Mónica T. Fernandes
- Escola Superior de Saúde, Universidade do Algarve, Faro, Portugal
- Algarve Biomedical Center, Universidade do Algarve, Faro, Portugal
- Algarve Biomedical Center Research Institute, Universidade do Algarve, Faro, Portugal
| | | | - Ana Paula Silva
- Serviço de Nefrologia, Centro Hospitalar Universitário do Algarve, Faro, Portugal
- Faculdade de Medicina e Ciências Biomédicas, Universidade do Algarve, Faro, Portugal
| | - José Bragança
- Faculdade de Medicina e Ciências Biomédicas, Universidade do Algarve, Faro, Portugal
- Algarve Biomedical Center, Universidade do Algarve, Faro, Portugal
- Algarve Biomedical Center Research Institute, Universidade do Algarve, Faro, Portugal
- Champalimaud Research Program, Champalimaud Center for the Unknown, Lisbon, Portugal
| | - Anabela Rodrigues
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- Serviço de Nefrologia, Centro Hospitalar Universitário do Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
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Do JY, Kim AY, Kang SH. Peritoneal Protein Loss Is Not Associated With Sarcopenia in Peritoneal Dialysis Patients. Front Med (Lausanne) 2021; 8:653807. [PMID: 34336874 PMCID: PMC8316630 DOI: 10.3389/fmed.2021.653807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/17/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Maintenance of a peritoneal membrane is essential for maintaining long-term peritoneal dialysis (PD). Peritoneal protein loss (PPL) is basically the loss of an essential nutrient, which may lead to malnutrition. We aimed to evaluate the association between PPL and sarcopenia in PD patients. Methods: We conducted a cross-sectional study from September 2017 to November 2020 on all PD patients (n = 199). Finally, the patients were divided into tertiles based on the PPL level as follows: low, middle, and high. PPL (mg/day), appendicular lean mass (ALM) using dual-energy X-ray absorptiometry, and handgrip strength (HGS) were evaluated. Sarcopenia was defined using cut-off values from the Asian Working Group for Sarcopenia. Results: The median PPL (interquartile range, interval) in the low, middle, and high tertiles were 4,229 (904, 1,706–5,111), 6,160 (760, 5,118–7,119), and 8,543 (2,284, 7,145–24,406) mg/day, respectively. HGS in the low, middle, and high tertiles was 23.4 ± 9.2, 23.8 ± 8.9, and 23.6 ± 8.3 kg, respectively (P = 0.967). The ALM index in the low, middle, and high tertiles was 6.0 ± 1.3, 6.0 ± 1.2, and 6.5 ± 1.1 kg/m2, respectively (P = 0.061). Multivariate analyses did not reveal significant differences in HGS and ALM index in among tertiles. The proportions of patients with sarcopenia in the low, middle, and high tertiles was 24 (36.4%), 19 (28.4%), and 21 (31.8%), respectively (P = 0.612). Conclusion: The present study showed that PPL is not independently associated with muscle mass, strength, and sarcopenia in PD patients.
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Affiliation(s)
- Jun Young Do
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, South Korea
| | - A Young Kim
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Seok Hui Kang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, South Korea
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Szeto CC, Kong J, Wu AK, Wong TY, Wang AY, Li PK. The Role of Lean Body Mass as a Nutritional Index in Chinese Peritoneal Dialysis Patients—Comparison of Creatinine Kinetics Method and Anthropometric Method. Perit Dial Int 2020. [DOI: 10.1177/089686080002000622] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To compare, in Chinese continuous ambulatory peritoneal dialysis (CAPD) patients, the creatinine kinetics method (LBM-CK) and the anthropometric method (LBM-AM) for determining lean body mass (LBM). Design Single-center cross-sectional study. Patients and Methods We studied 151 unselected CAPD patients (78 males, 73 females). We calculated LBM-CK and LBM-AM using standard formulas. The results of the two methods were then compared by the Bland and Altman method. Dialysis adequacy and other nutritional indices, including total Kt/V, weekly creatinine clearance (CCr), residual glomerular filtration rate (GFR), protein nitrogen appearance (PNA), subjective global assessment (SGA), and serum albumin, were measured simultaneously. Results The mean age of the patients was 55.6 ± 12.2 years, and the mean duration of dialysis was 33.6 ± 28.5 months. The mean body mass index (BMI) was 22.7 ± 3.7. The average LBM-AM was 43.6 ± 8.0 kg; the average LBM-CK was 33.0 ± 9.3 kg. The difference between the calculated LBM-AM and LBM-CK was 10.7 kg, with LBM-AM always giving a higher value; the limits of agreement were –5.8 kg and 27.1 kg. The difference between the two measures correlated with residual GFR (Pearson r = 0.629, p < 0.001). After normalizing for desired body weight, LBM-AM was only modestly correlated with serum albumin level. No correlations were found between overall SGA score or normalized protein nitrogen appearance (nPNA) and LBM-AM or LBM-CK. Conclusions In Chinese patients at least, a substantial discrepancy exists between LBM-AM and LBM-CK. The difference is especially marked in patients with significant residual renal function. The optimal method for determining LBM remains obscure in Chinese CAPD patients. Moreover, LBM correlated poorly with other nutritional indices. Multiple parameters should be taken into consideration in an assessment of nutritional status of CAPD patients.
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Johnathan Kong
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Alan K.L. Wu
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Teresa Y.H. Wong
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Angela Y.M. Wang
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Philip K.T. Li
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Han DS, Hwang JH, Kang DH, Song HY, Noh H, Shin SK, Lee SW, Kang SW, Choi KH, Ha SK, Lee HY. Current Status of Peritoneal Dialysis in Korea: Efforts to Achieve Optimal Outcome. Perit Dial Int 2020. [DOI: 10.1177/089686089901903s04] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Since its introduction in 1981, peritoneal dialysis (PD) has become firmly established as an effective mode of renal replacement therapy and serves an increasing patient population in Korea. The latest registry data indicate that about 3700 end-stage renal disease patients are maintained on chronic PD, representing 24.1% of the country's dialysis population. The majority (93.3%) of these patients are on continuous ambulatory peritoneal dialysis (CAPD) using the two-bag disconnect system, while only 3.3% are on automated PD. Under current renal reimbursement policies, most dialysis patients have to pay 20% of dialysis fees. Thus CAPD patients on 4 x 2-L daily exchanges pay about US$200 per month, not including medication and travel costs. Traditionally, most PD centers in Korea have used the “standard” prescription of 4 exchanges of 2 L of solution for most of their patients. A recent survey of 1467 patients who commenced CAPD in 1997 revealed that 84% of these patients were initially prescribed 4 x 2-L exchanges, while 12% were given a daily volume of 6 L. With this standard prescription, the percentages of Korean CAPD patients initially achieving the adequacy target of Kt/V urea ≥ 2.0 and standardized creatinine clearance (SCCr) ≥ 60 L/week/ 1.73 m2, were 74.4% and 82.1%, respectively. It is likely that, among current Korean CAPD patients, a much lower percentage will achieve the clearance targets compared to this initial outcome, but the precise data are not available. However, it is not clear whether the levels of small-solute clearance recommended for optimal PD outcomes, and proposed by the NKF-DOQI guidelines, will bring the expected benefits to Korean patients. Overall survival of Korean PD patients appears to be as good as, or even better than, that in most other countries. Recently, a single large PD center reported patient survival of 92.1%, 85.6%, 81.4%, and 67.6% at 1, 2, 3, and 5 years respectively. Other centers also reported similar outcomes. As in other countries, cardiovascular deaths predominate among Korean patients: death was due to cardiac causes in 29%, to vascular causes in 21%, and to infectious causes in 24%. Peritonitis is the most important barrier to prolonged use of CAPD in Korea, and more PD patients transfer to hemodialysis because of peritonitis than in other countries. To further reduce the morbidity and mortality of Korean PD patients, various control measures need to be implemented that can reduce or prevent peritonitis and other infectious complications. Also, to further improve long-term patient outcome, Korean nephrologists need to establish and practice optimal clearance targets in the chronic care of these patients.
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Affiliation(s)
- Dae-Suk Han
- Department of Internal Medicine, Yonsei University College of Medicine, Incheon, Korea
| | - Jae-Ha Hwang
- Department of Internal Medicine, Yonsei University College of Medicine, Incheon, Korea
| | - Duk-Hee Kang
- Department of Internal Medicine, Ewha Women's University College of Medicine, Seoul
| | - Hyun-Yong Song
- Department of Internal Medicine, Yonsei University College of Medicine, Incheon, Korea
| | - Hyunjin Noh
- Department of Internal Medicine, Yonsei University College of Medicine, Incheon, Korea
| | - Sug-Kyun Shin
- Department of Internal Medicine, Yonsei University College of Medicine, Incheon, Korea
| | - Seoung-Woo Lee
- Department of Medicine, Inha University College of Medicine, Incheon, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Incheon, Korea
| | - Kyu-Hun Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Incheon, Korea
| | - Sung-Kyu Ha
- Department of Internal Medicine, Yonsei University College of Medicine, Incheon, Korea
| | - Ho-Yung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Incheon, Korea
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Lee HY, Park HC, Seo BJ, Do JY, Yun SR, Song HY, Kim YH, Kim YL, Kim DJ, Kim YS, Ahn C, Kim MJ, Shin SK. Superior Patient Survival for Continuous Ambulatory Peritoneal Dialysis Patients Treated with a Peritoneal Dialysis Fluid with Neutral pH and Low Glucose Degradation Product Concentration (Balance). Perit Dial Int 2020. [DOI: 10.1177/089686080502500308] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background In recent years, laboratory and clinical research has suggested the need for peritoneal dialysis fluids (PDFs) that are more biocompatible than the conventional PDFs commonly used today. Bioincompatibility of PDF has been attributed to low pH, lactate, glucose, glucose degradation products (GDPs), and osmolality. PDFs with neutral pH and low GDPs are now available commercially. In vitro and early clinical studies suggest that these solutions are indeed more biocompatible but, as of now, there is no evidence that their use improves patient outcome. Methods Using a dedicated database of over 2000 patients treated with PD in Korea, we were able to conduct a retrospective observational study comparing outcomes for incident continuous ambulatory PD patients treated with a standard, conventional, heat-sterilized PDF to the outcomes for patients treated with a novel, low GDP, neutral-pH PDF prepared in a dual-compartment, double-bag PD system (Balance; Fresenius Medical Care, St. Wendel, Germany). In an intention-to-treat analysis, patient and technique survival, peritonitis-free survival, and peritonitis rates were compared in 611 patients treated with Balance for up to 30 months and 551 patients with a standard PDF (stay·safe; Fresenius Medical Care) treated in the same era and with equivalent follow-up. Results The patients were well matched for most relevant characteristics except older age distribution for the patients treated with the standard PDF. Patients treated with Balance had significantly superior survival compared to those treated with the standard PDF (74% vs 62% at 28 months, p = 0.0032). In a multivariate Cox regression model including age, diabetes, and gender, the survival advantage persisted (relative risk of death for Balance 0.75, 95% confidence interval 0.56 – 0.99, p = 0.0465). Modality technique survival was similar in Kaplan–Meier analysis for both PDFs. No differences were detected in peritonitis-free survival or in peritonitis rates between the two solutions. Conclusion This study, for the first time, suggests that treatment with a novel biocompatible PDF with low GDP concentration and neutral pH confers a significant survival advantage. The exact mechanisms for such a survival advantage cannot be determined from this study. The usual criticisms of observational studies apply and the results reported here strongly warrant the undertaking of appropriately designed, randomized, controlled clinical trials.
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Affiliation(s)
- Ho Yung Lee
- Department of Internal Medicine, College of Medicine Yonsei University, Seoul
| | - Hyeong Cheon Park
- Department of Internal Medicine, College of Medicine Yonsei University, Seoul
| | | | | | | | | | | | | | | | | | | | | | - Sug Kyun Shin
- National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
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Jones CH, Newstead CG. The Ratio of Extracellular Fluid to Total Body Water and Technique Survival in Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080402400410] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BackgroundPatients receiving peritoneal dialysis experience a high technique failure rate and are often overhydrated. We examined whether an increased extracellular fluid volume (VECF) as a proportion of the total body water (VTBW) predicted technique survival (TS) in a prevalent patient cohort.MethodsThe VECFand VTBWwere estimated by multiple-frequency bioelectric impedance in 59 prevalent peritoneal dialysis patients (median time on dialysis 14 months). Demographic, biochemical (albumin, C-reactive protein, and ferritin), and anthropometric data, forearm muscle strength, nutritional score by three-point Subjective Global Assessment, residual renal function, dialysate-to-plasma (D/P) creatinine ratio, total weekly Kt/V urea, total creatinine clearance, normalized protein equivalent of nitrogen appearance, and midarm muscle circumference were also assessed. Technique survival was determined at 3 years, and significant predictors of TS were sought.ResultsIn patient groups defined by falling above or below the median value for each parameter, only residual renal function ( p = 0.002), 24-hour ultrafiltrate volume ( p = 0.02), and VECF/ VTBWratio ( p = 0.05) were significant predictors of TS. Subjects with a higher than median VECF/ VTBWratio had a 3-year TS of 46%, compared to 78% in subjects with a lower than median value. In multivariate analysis, systolic blood pressure and VECF/ VTBWratio (both p < 0.05) were significant predictors of TS. C-reactive protein approached significance.ConclusionIncreased ratio of extracellular fluid volume to total body water is associated with decreased TS in peritoneal dialysis.
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Kang DH, Kang EW, Choi SR, Yoon SY, Han DS. Nutritional Problems of Asian Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080302302s13] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Clear evidence links malnutrition with poor outcome in peritoneal dialysis (PD) patients; however, most studies have evaluated Western populations, which may have clinical and demographic characteristics different from those of Asian populations. Although Asian PD patients are generally regarded to have survival superior to that of Western patients, whether that better survival is related to better nutrition in Asian patients is not clear. Past studies suggest that the overall prevalence of protein–calorie malnutrition as assessed by subjective global assessment (SGA)—especially cases of severe malnutrition—seems to be lower in Asian PD patients than in Western patients. Less activation of systemic inflammatory reaction, less comorbidity, lower prevalence of metabolic acidosis, or better compliance may be responsible for better nutritional status in Asian PD patients. Dietary protein and calorie intake, dialysis dose, and membrane transport characteristics appear not to differ significantly between Asian and non Asian PD patients. Mechanisms that explain the lower prevalence of systemic inflammatory reaction in Asian PD patients need to be investigated, along with their possible impacts on nutrition and cardiovascular morbidity and mortality. Large-scale, prospective studies are also necessary to ascertain the exact correlation between dialysis dose and nutritional status, and to determine the dietary protein and calorie intakes that maintain a positive nitrogen balance and better outcome in Asian PD patients.
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Affiliation(s)
- Duk-Hee Kang
- Division of Nephrology, Institute of Kidney Disease, College of Medicine, Yonsei University, Seoul, Korea
| | - Ea Wha Kang
- Ewha Women's University College of Medicine, and Department of Internal Medicine, Institute of Kidney Disease, College of Medicine, Yonsei University, Seoul, Korea
| | - So Rae Choi
- Ewha Women's University College of Medicine, and Department of Internal Medicine, Institute of Kidney Disease, College of Medicine, Yonsei University, Seoul, Korea
| | - Soo-Young Yoon
- Ewha Women's University College of Medicine, and Department of Internal Medicine, Institute of Kidney Disease, College of Medicine, Yonsei University, Seoul, Korea
| | - Dae-Suk Han
- Ewha Women's University College of Medicine, and Department of Internal Medicine, Institute of Kidney Disease, College of Medicine, Yonsei University, Seoul, Korea
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Sutton D, Talbot ST, Stevens JM. Is There a Relationship between Diet and Nutrition Status in Continuous Ambulatory Peritoneal Dialysis Patients? Perit Dial Int 2020. [DOI: 10.1177/089686080102103s28] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Chung SH, Heimbürger O, Stenvinkel P, Wang T, Lindholm B. Influence of Peritoneal Transport Rate, Inflammation, and Fluid Removal on Nutritional Status and Clinical Outcome in Prevalent Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080302300214] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the possible associations between peritoneal transport rate (PTR), fluid removal, inflammation, and nutritional status in patients treated with peritoneal dialysis (PD) for more than 6 months, and the impact of these factors on subsequent patient survival. Design and Patients A prospective study of 82 PD patients (48 males) that had been treated with PD more than 6 months. Based on the dialysate-to-plasma creatinine ratio at 4 hours of dwell (D/PCr; mean ± 1 SD), the patients were classified as having a high (H), high-average (HA), low-average (LA), or low (L) PTR. Setting Single PD unit in a university hospital. Main Outcome Measures The PTR, evaluation of adequacy of dialysis and nutritional status, and biochemical analyses were assessed at 10.8 ± 2.8 months after the start of PD. Results Compared to L and LA (L/LA) transporters, H and HA (H/HA) transporters had increased dialysate protein loss, glucose absorption from dialysate, and peritoneal creatinine clearance (CCr), and decreased night ultrafiltration volume and total Kt/V urea. However, nutritional variables, 24-hour total fluid removal (TFR), total CCr, and residual renal function were not significantly different between the two groups. The 24-hour TFR correlated significantly with D/PCr (rho = –0.25), mean arterial pressure (rho = –0.23), serum albumin (rho = 0.25), normalized protein equivalent of total nitrogen appearance (rho = 0.34), lean body mass (LBM) calculated from creatinine kinetics (rho = 0.41), total Kt/V urea (rho = 0.42), and total CCr (rho = 0.30). The group with serum C-reactive protein (sCRP) ⊕ 10 mg/L had a higher proportion of patients with reduced (< 1000 mL) TFR compared to the group with sCRP < 10 mg/(38% vs 16%, p = 0.04). Two-year patient survival rates from the time of the assessment were not different between the different transport groups (78% vs 73% for H/HA and L/LA, p = 0.99). Upon Cox proportional hazards multivariate analysis, age and high sCRP were independent predictors of mortality. Conclusions This study shows that, in a selected group of prevalent PD patients assessed after more than 6 months of PD therapy, ( 1 ) inflammation was an independent predictor for mortality; ( 2 ) reduced TFR was associated with impaired nutritional status, decreased small solute clearance, and inflammation; and ( 3 ) peritoneal transport status was not significantly associated with nutritional status and was not associated with subsequent patient survival. These results indicate that a high peritoneal solute transport rate, as such, should not be regarded as a relative contraindication for PD. Instead, the results suggest that more attention should be given to inflammation and inadequate fluid removal as predictors of mortality in PD patients.
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Affiliation(s)
- Sung Hee Chung
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
- Hyonam Kidney Laboratory, Soon Chun Hyang University, Seoul, Korea
| | - Olof Heimbürger
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
| | - Peter Stenvinkel
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
| | - Tao Wang
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
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Gomes AM, Pérez–Fontán M, Rodríguez–Carmona A, López–Muñiz A, Fernández–Villar M, Peteiro–Cartelle J, García–Falcón T. Peritoneal Total Protein Transport Assessed from Peritoneal Equilibration Tests Using Different Dialysate Glucose Concentrations. Perit Dial Int 2020; 30:549-57. [DOI: 10.3747/pdi.2009.00127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BackgroundThe peritoneal equilibration test (PET) permits assessment of peritoneal protein transport, but this potential marker of outcome in peritoneal dialysis (PD) patients lacks adequate standardization.ObjectivesTo assess various approaches for estimation of peritoneal protein transport in PD patients during 2.27% and 3.86% glucose-based PETs, and to uncover the demographic, clinical, and biochemical correlates of this phenomenon.Patients and MethodsWe studied 90 PD patients who underwent 2.27% and 3.86% PETs in random order, and we used multivariate analysis to compare assessments of peritoneal protein transport in both tests, searching for correlations between D240′– D0′protein concentration (PETΔPConc), total peritoneal protein excretion (PET-PPE), or total protein clearance (PET-PC) on the one hand (the main study variables), and PET-derived markers of peritoneal function and selected demographic, clinical, and biochemical variables on the other.ResultsThe PETΔPConc was higher during the 2.27% PET (mean: 45.2 mg/dL vs 37.0 mg/dL for the 3.86% test; p = 0.003); the PET-PPE and PET-PC were comparable (1121.8 mg vs 1168.9 mg, p = 0.52, and 17.1 mL vs 17.8 mL, p = 0.66, respectively). All three variables sustained a significant, yet moderate correlation (all r2values < 0.30) with the 24-hour PPE rate. Multivariate analysis identified dialysate-to-plasma ratio (D/P240′) of creatinine, end-to-initial dialysate ratio (D240′/D0′) of glucose, current daily peritoneal glucose load, ultrafiltration during PET, systolic blood pressure, and previous cardiovascular events (3.86% test only) as independent predictors of protein transport during PET.ConclusionsEither PET-PPE or PET-PC seems preferable to PETΔPConc for characterization of peritoneal protein transport. Small-solute transport characteristics, ultrafiltration, and current peritoneal glucose load sustain independent correlations with peritoneal protein transport. The latter variable shows also a moderate association with markers of cardiovascular disease in PD patients.
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Affiliation(s)
- Ana Marta Gomes
- Division of Nephrology, Complejo Hospitalario Universitario de A Coruña
| | - Miguel Pérez–Fontán
- Division of Nephrology, Complejo Hospitalario Universitario de A Coruña
- Department of Medicine, Health Sciences Institute, University of A Coruña
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13
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Guedes AM. Peritoneal Protein Loss, Leakage or Clearance in Peritoneal Dialysis, Where do we Stand? Perit Dial Int 2019; 39:201-209. [DOI: 10.3747/pdi.2018.00138] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 12/28/2018] [Indexed: 11/15/2022] Open
Abstract
Peritoneal protein loss (PPL) through peritoneal effluent has been a well-recognized detrimental result of peritoneal dialysis (PD) treatment since its inception. Investigation has focused mainly on PPL quantitative and qualitative determinations and evaluation of its prognostic value. A comprehensive review of the pathophysiology of PPL (3-pore model revisited), methods of quantification, dialysate protein composition, and impact on clinical outcomes is presented herein. The author summarizes a brief analysis of associated cardiovascular disease and nutritional consequences, exploring the controversial cause-effect on mortality and technique failure. Therapeutic modalities aiming to reduce PPL (angiotensin-converting enzyme inhibitors [ACEI]s and vitamin D therapies) were explored, although it is unclear whether PPL represents a valid therapeutic target or, on the other hand, is solely a manifestation of endothelial dysfunction.
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Affiliation(s)
- Anabela Malho Guedes
- Serviço de Nefrologia, Centro Hospitalar Universitário do Algarve, Faro, Portugal; Algarve Biomedical Center, Faro, Portugal
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14
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Affiliation(s)
- J.Y. Yeun
- Medicine Service, Nephrology Section, Department of Veterans Affairs Northern California Health Care System, Mather, California, and University of California Davis Medical Center, Sacramento, California - USA
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15
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Yan X, Yang X, Xie X, Xiang S, Zhang X, Shou Z, Chen J. Association Between Comprehensive Nutritional Scoring System (CNSS) and Outcomes of Continuous Ambulatory Peritoneal Dialysis Patients. Kidney Blood Press Res 2017; 42:1225-1237. [PMID: 29248920 DOI: 10.1159/000485926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 12/03/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The presence of protein-energy wasting (PEW) among dialysis patients is a crucial risk factor for outcomes. The complicated pathogenesis of PEW makes it difficult to assess and treat. This single-center retrospective study focuses on the association between nutritional markers and the outcomes of continuous ambulatory peritoneal dialysis(CAPD) patients, aiming to establish a practical comprehensive nutritional scoring system for CAPD patients. METHODS 924 patients who initiated peritoneal dialysis in our center from January 1st,2005 to December 31st,2015 were enrolled. Comprehensive nutritional scoring system(CNSS) was based on items including SGA, BMI, ALB, TC, MAC and TSF. We divide patients into 3 groups according to their CNSS score. Outcomes including mortality, hospitalization days and hospitalization frequency were compared between 3 grades. RESULTS The CNSS grade correlated significantly with hospitalization days (P<0.05). Both categorized CNSS grade (HR:0.56; 95% CI:0.41-0.78; P = 0.001) and continuous CNSS score (HR:0.87; 95% CI: 0.80-0.94; P = 0.001) independently protect PD patients from all-cause mortality. CONCLUSION CNSS provides an integrated scoring system with significant associations with hospitalization and mortality in PD patients. The CNSS grade differentiates patients with malnutritional risk and independently predicts high risk of morbidity and mortality.
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Affiliation(s)
- Xingqun Yan
- aKidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xin Yang
- aKidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xishao Xie
- aKidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shilong Xiang
- aKidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaohui Zhang
- aKidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhangfei Shou
- bKidney Disease Center, International Hospital of Zhejiang University, Shulan (Hangzhou) Hospital,, Hangzhou, China
| | - Jianghua Chen
- aKidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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16
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Kwon YE, Kee YK, Yoon CY, Han IM, Han SG, Park KS, Lee MJ, Park JT, Han SH, Yoo TH, Kim YL, Kim YS, Yang CW, Kim NH, Kang SW. Change of Nutritional Status Assessed Using Subjective Global Assessment Is Associated With All-Cause Mortality in Incident Dialysis Patients. Medicine (Baltimore) 2016; 95:e2714. [PMID: 26886609 PMCID: PMC4998609 DOI: 10.1097/md.0000000000002714] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Subjective global assessment (SGA) is associated with mortality in end-stage renal disease (ESRD) patients. However, little is known whether improvement or deterioration of nutritional status after dialysis initiation influences the clinical outcome. We aimed to elucidate the association between changes in nutritional status determined by SGA during the first year of dialysis and all-cause mortality in incident ESRD patients. This was a multicenter, prospective cohort study. Incident dialysis patients with available SGA data at both baseline and 12 months after dialysis commencement (n = 914) were analyzed. Nutritional status was defined as well nourished (WN, SGA A) or malnourished (MN, SGA B or C). The patients were divided into 4 groups according to the change in nutritional status between baseline and 12 months after dialysis commencement: group 1, WN to WN; group 2, MN to WN; group 3, WN to MN; and group 4, MN to MN. Cox proportional hazard analysis was performed to clarify the association between changes in nutritional status and mortality. Being in the MN group at 12 months after dialysis initiation, but not at baseline, was a significant risk factor for mortality. There was a significant difference in the 3-year survival rates among the groups (group 1, 92.2%; group 2, 86.0%; group 3, 78.2%; and group 4, 63.5%; log-rank test, P < 0.001). Multivariate Cox regression analysis revealed that the mortality risk was significantly higher in group 3 than in group 1 (hazard ratio [HR] 2.77, 95% confidence interval [CI] 1.27-6.03, P = 0.01) whereas the mortality risk was significantly lower in group 2 compared with group 4 (HR 0.35, 95% CI 0.17-0.71, P < 0.01) even after adjustment for confounding factors. Moreover, mortality risk of group 3 was significantly higher than in group 2 (HR 2.89, 95% CI 1.22-6.81, P = 0.02); there was no significant difference between groups 1 and 2. The changes in nutritional status assessed by SGA during the first year of dialysis were associated with all-cause mortality in incident ESRD patients.
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Affiliation(s)
- Young Eun Kwon
- From the Department of Internal Medicine (YEK, YKK, C-YY, IMH, SGH, KSP, MJL, JTP, SHH, T-HY, S-WK), Yonsei University College of Medicine, Seoul; Department of Internal Medicine (YLK), Kyungpook National University School of Medicine, Daegu; Department of Internal Medicine (YSK), Seoul National University College of Medicine; Department of Internal Medicine (CWY), Catholic University of Korea College of Medicine, Seoul; and Department of Internal Medicine (N-HK), Chonnam National University Medical School, Gwangju, South Korea
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17
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Baseline higher peritoneal transport had been associated with worse nutritional status of incident continuous ambulatory peritoneal dialysis patients in Southern China: a 1-year prospective study. Br J Nutr 2015; 114:398-405. [PMID: 26244901 DOI: 10.1017/s0007114515001804] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The aim of the present study was to investigate the relationship between baseline peritoneal transport types and nutritional status in Chinese continuous ambulatory peritoneal dialysis (CAPD) patients. In the present single-centre, prospective study, incident CAPD patients were included from 15 April 2010 to 31 December 2011 and were followed up for 12 months. According to the results of baseline peritoneal equilibration test, patients were divided into lower peritoneal transport group (lower transporters) and higher peritoneal transport group (higher transporters). Nutritional status was evaluated by both subjective global assessment (SGA) and protein-energy wasting (PEW) score. The body composition parameters were assessed by body impedance analysis. A total of 283 CAPD patients were included in the study, of which 171 (60.4 %) were males with a mean age of 47.0 (sd 14.9) years. Compared with lower transporters (n 92), higher transporters (n 181) had lower levels of serum albumin (37.1 (sd 4.3) v. 39.6 (sd 4.3) g/l, P< 0.001), serum pre-albumin (356 (sd 99) v. 384 (sd 90) mg/l, P= 0.035), phase angle (6.15 (sd 0.39) v. 6.27 (sd 0.47)°, P< 0.05) and higher rate of malnutrition defined by SGA (52.5 v. 25.0%, P< 0.001) and PEW score (37.0 v. 14.1 %, P< 0.001) at 1-year of follow-up. Baseline higher peritoneal transport, analysed by multivariate binary logistic regressions, was independently associated with malnutrition (SGA mild to moderate and severe malnutrition: OR 3.43, 95% CI 1.69, 6.96, P< 0.01; PEW: OR 2.40, 95% CI 1.08, 5.31, P= 0.03). It was concluded that baseline higher peritoneal transport was independently associated with worse nutritional status of CAPD patients in Southern China.
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18
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Shioya M, Yoshida T, Kasai K, Furuya R, Kato A, Mori N, Matsumoto Y, Kumagai H. Inflammatory factors for hypoalbuminemia in Japanese peritoneal dialysis patients. Nephrology (Carlton) 2014; 18:539-44. [PMID: 23718260 DOI: 10.1111/nep.12106] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2013] [Indexed: 11/28/2022]
Abstract
AIM Hypoalbuminaemia is a common complication of peritoneal dialysis (PD), and the leakage of albumin through peritoneal membrane may be a principal reason for hypoalbuminaemia. However, the relationship between peritoneal inflammation, peritoneal transport properties and hypoalbuminaemia has not been fully elucidated. METHODS A cross-sectional study was performed on 76 Japanese PD patients who had been using a low-glucose PD solution and icodextrin. Systemic inflammatory markers of C-reactive protein (CRP) and serum interleukin-6 (IL-6), peritoneal effluent markers of dialysate IL-6 and CA125, the dialysate-to-plasma ratio of creatinine (D/Pcr) and the dialysate protein concentration were measured and examined for their relationship with hypoalbuminaemia. RESULTS There was a significant positive correlation between serum IL-6 and dialysate IL-6, mean dialysate IL-6 being significantly higher than mean serum IL-6, suggesting that intraperitoneal inflammation was a principal origin of systemic inflammation. Both serum and dialysate IL-6 were significantly correlated with serum albumin (r= -0.25, P<0.05 and r=-0.32, P<0.01, respectively). Dialysate IL-6 was significantly correlated with D/Pcr and the dialysate protein concentration, and there was a significantly positive association between D/Pcr and the dialysate protein concentration. Dialysate CA125, which is argued to be a marker of mesothelial cell mass in this study, was positively correlated with D/Pcr and the dialysate protein concentration. The dialysate protein, dialysate IL-6 and dialysate CA125 all increased according to the peritoneal transport rate defined by D/Pcr. A multiple-regression analysis showed that serum albumin was independently associated with the age, D/Pcr and serum IL-6. CONCLUSION Hypoalbuminaemia was attributable to both the increased peritoneal permeability and systemic inflammation, and intraperitoneal inflammation might contribute to developing these complications.
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Affiliation(s)
- Masuyo Shioya
- Department of Clinical Nutrition, School of Food and Nutritional Sciences, University of Shizuoka, Shizuoka, Japan
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19
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Naylor HL, Jackson H, Walker GH, Macafee S, Magee K, Hooper L, Stewart L, MacLaughlin HL. British Dietetic Association evidence-based guidelines for the protein requirements of adults undergoing maintenance haemodialysis or peritoneal dialysis. J Hum Nutr Diet 2013; 26:315-28. [PMID: 23731266 DOI: 10.1111/jhn.12052] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Existing nutritional guidelines suggest that protein requirements of adults with stage five chronic kidney disease undergoing haemodialysis (HD) or peritoneal dialysis (PD) are increased as a result of protein losses during dialysis. The present review aimed to update previous guidance and develop evidence-based practice guidelines on the protein requirements of adults undergoing maintenance dialysis. METHODS Following a PICO approach (Participants or Population, Intervention or Exposure, Comparison and Outcome), four research questions were formulated to investigate the total protein requirement and protein quality required by adults undergoing HD and PD. A comprehensive, systematic review was undertaken using the databases Medline, EMBASE and the Cochrane Library from 2005 to September 2009 for HD studies and from 1997 to September 2009 for PD studies. RESULTS The literature search yielded 2931 studies, which were assessed for inclusion. Following appraisal, 19 studies in HD and 18 studies in PD met the inclusion criteria and were systematically reviewed. Limited good quality evidence supports the recommendations that: (i) adults undergoing maintenance HD require a minimum protein intake of 1.1 g kg(-1) ideal body weight (IBW) per day; and (ii) adults undergoing maintenance PD require a minimum protein intake of 1.0-1.2 kg(-1) IBW per day, in conjunction with an adequate energy intake. There were no studies that addressed the quality of protein for either HD or PD. CONCLUSIONS Evidence suggests that nutritional status may be maintained with lower protein intakes than previously recommended. However, the evidence base is limited and further randomised controlled trials are required to establish the optimal protein intake for dialysis patients.
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Affiliation(s)
- H L Naylor
- Betsi Cadwaladr University Health Board, Bangor, UK.
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20
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Tennankore KK, Bargman JM. Nutrition and the kidney: recommendations for peritoneal dialysis. Adv Chronic Kidney Dis 2013; 20:190-201. [PMID: 23439379 DOI: 10.1053/j.ackd.2012.10.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 10/19/2012] [Accepted: 10/25/2012] [Indexed: 12/22/2022]
Abstract
Protein energy wasting (PEW) is highly prevalent in peritoneal dialysis (PD) and is associated with poor outcomes, including hospitalization and mortality. Recognizing and diagnosing PEW in PD is important; although studies are limited, there are interventions that may be associated with improved outcomes. In this review of nutritional aspects of PD, we highlight some of the important causes of PEW and explore the current diagnostic tools that are used to assess PEW. Finally, we discuss the established and experimental therapies for PEW in PD.
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Velozo KDS, Ferraz S, Raimundo MC, Figueiredo AEPL. [Assessment of body weight changes in patients on peritoneal dialysis]. Rev Gaucha Enferm 2012; 33:160-6. [PMID: 23155595 DOI: 10.1590/s1983-14472012000200023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This study had as its main objective to assess the variation in body weight of patients on peritoneal dialysis (DP) during the first year of treatment and as a secondary goal to identify patients with criteria for metabolic syndrome (SM). Observational study conducted with 35 patients of a university hospital. Data were collected on the clinical and demographic status, change of body weight and criteria for SM from the sample. After 12 months of initiation of dialysis, approximately 40% of patients showed overweight and/or obesity. The average variation of body weight after one year was 3.7 Kg, and the largest variation was found in the first three months, with values of 2.2 Kg The prevalence of SM was 30%. It was concluded that the most important change of body weight happened in the first year of treatment and there is a high prevalence of SM in patients on DP.
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Henriques VT, Martinez EZ, Divino-Filho JC, Pecoits-Filho R, da Costa JAC. Increase in BMI over time is associated with fluid overload and signs of wasting in incident peritoneal dialysis patients. J Ren Nutr 2012; 23:e51-7. [PMID: 23046738 DOI: 10.1053/j.jrn.2012.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 08/23/2012] [Accepted: 08/25/2012] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES Peritoneal dialysis (PD) patients may suffer changes in nutritional status after starting PD. Several markers can be used to evaluate these modifications, such as body mass index (BMI), serum albumin, and serum creatinine. Fluid overload should be considered because it can overestimate or underestimate nutritional status. The objective of this study was to evaluate the BMI changes over time in incident PD patients and identify interactions among BMI, signs of fluid overload, serum albumin, and serum creatinine. DESIGN The study included a cohort of 1,997 incident PD patients of the BRAZPD recruited from 2004 to 2007. Sociodemographic data and BMI classification were obtained at baseline. The evolutions of BMI and body weight were assessed over a period of 29 months. Changes in the evolution were analyzed when a patient presented with albumin < 3.8 g/dL, creatinine < 7.0 mg/dL, or the presence of edema. Data analysis was performed using linear mixed-effects regression models as the main statistical procedure. RESULTS BMI increased over time (29 months) by an average of 0.05 kg/m(2) per month, and body weight increased by 0.11 kg/month for a total increase of 3.08 kg. BMI decreased by 0.12 kg/m(2) in the presence of albumin < 3.8 g/dL and by 0.38 kg/m(2) in the presence of creatinine < 7.0 mg/dL. BMI increased by 0.61 kg/m(2) in the presence of edema. BMI increased in the presence of edema and albumin < 3.8 mg/dL or edema and creatinine < 7.0 mg/dL. CONCLUSIONS There is a mean increase in the BMI of incident PD patients over time, and these changes may be, at least partly, due to fluid overload, leading to distortions of body weight. When the patients presented with lower serum albumin or creatinine levels, the BMI values were reduced, suggesting that a reduction in lean mass and an increase in fat mass may be occurring in these patients.
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Abstract
Protein-energy wasting (PEW) is prevalent among patients on dialysis and has emerged as an important risk factor for morbidity and mortality in these patients. Numerous factors, including inflammation, inadequate dialysis, insufficient nutrient intake, loss of protein during dialysis, chronic acidosis, hypercatabolic illness and comorbid conditions, are involved in the development of PEW. The causes and clinical features of PEW in patients on peritoneal dialysis and hemodialysis are comparable; assessment of the factors that lead to PEW in patients receiving peritoneal dialysis is important to ensure that PEW is managed correctly in these patients. For the past 20 years, much progress has been made in the prevention and treatment of PEW. However, the results of most nutritional intervention studies are inconclusive. In addition, the multifactorial and complicated pathogenesis of PEW makes it difficult to assess and treat. This Review summarizes the nutritional issues regarding the causes, assessment and treatment of PEW, with a focus on patients receiving peritoneal dialysis. In addition, an in-depth overview of the results of nutritional intervention studies is provided.
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Jiang N, Qian J, Lin A, Fang W, Zhang W, Cao L, Wang Q, Ni Z, Yao Q. Low-protein diet supplemented with keto acids is associated with suppression of small-solute peritoneal transport rate in peritoneal dialysis patients. Int J Nephrol 2011; 2011:542704. [PMID: 21747999 PMCID: PMC3124873 DOI: 10.4061/2011/542704] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Accepted: 05/01/2011] [Indexed: 11/26/2022] Open
Abstract
Objective. We investigate whether low-protein diet would show benefits in suppressing peritoneal transport rate in peritoneal dialysis (PD) patients. Methods. This is a supplemented analysis of our previously published trial, which randomized 60 PD patients to receive low- (LP: dietary protein intake of 0.6-0.8 g/kg/d), keto-acid-supplemented low- (sLP: 0.6-0.8 g/kg/d with 0.12 g/kg/d of keto acids), or high- (HP: 1.0-1.2 g/kg/d) protein diet and lasted for one year. In this study, the variations of peritoneal transport rate were assessed. Results. While baseline D/P(cr) (dialysate-to-plasma concentration ratio for creatinine at 4 hour) and D/D0(glu) (dialysate glucose at 4 hour to baseline dialysate glucose concentration ratio) were similar, D/P(cr) in group sLP was lower, and D/D0(glu) was higher than those in the other two groups (P < 0.05) at 12th month. D/D0(glu) increased (P < 0.05), and D/P(cr) tended to decrease, (P = 0.071) in group sLP. Conclusions. Low-protein diet with keto acids may benefit PD patients by maintaining peritoneum at a lower transport rate.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Qiang Yao
- Renal Division, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Center for Peritoneal Dialysis Research, Shanghai 200001, China
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Chang TI, Park JT, Lee DH, Lee JH, Yoo TH, Kim BS, Kang SW, Lee HY, Choi KH. High peritoneal transport status is not an independent risk factor for high mortality in patients treated with automated peritoneal dialysis. J Korean Med Sci 2010; 25:1313-7. [PMID: 20808674 PMCID: PMC2923779 DOI: 10.3346/jkms.2010.25.9.1313] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Accepted: 02/09/2010] [Indexed: 11/28/2022] Open
Abstract
We undertook this study to elucidate whether baseline peritoneal membrane transport characteristics are associated with high mortality in incident automated peritoneal dialysis (APD) patients. This retrospective study includes 117 patients who started APD at Yonsei University Health System from 1996 to 2008 and had a PET within 3 months of APD initiation. High transporters were significantly older and had a higher incidence of cardiovascular disease. Patient survival for years 1, 3, and 5 were 85%, 64%, and 35% for high transporter and 94%, 81%, and 68% for non-high transporter group (P<0.01). Multivariate analysis revealed that age, diabetes, cardiovascular disease, serum albumin level, and residual renal function were independently associated with high mortality in APD patients. In contrast, high transport status was not a significant predictor for mortality in this population when the other covariates were included. Even though high transport was significantly associated with mortality in the univariate analysis, its role seemed to be influenced by other comorbid conditions. These findings suggest that the proper management of these comorbid conditions, as well as appropriate ultrafiltration by use of APD and/or icodextrin, must be considered as protective strategies to improve survival in peritoneal dialysis patients with high transport.
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Affiliation(s)
- Tae Ik Chang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Tak Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hyung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ju Hyun Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hyun Yoo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Beom Seok Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Yung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Bakkaloglu SA, Saygili A, Sever L, Aksu N, Noyan A, Akman S, Ekim M, Doganay B, Yildiz N, Akalin F, Caliskan S, Kara OD, Duzova A, Soylu A, Atalay S. Impact of peritoneal transport characteristics on cardiac function in paediatric peritoneal dialysis patients: a Turkish Pediatric Peritoneal Dialysis Study Group (TUPEPD) report. Nephrol Dial Transplant 2010; 25:2296-303. [PMID: 20139065 DOI: 10.1093/ndt/gfq027] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The peritoneal equilibration test (PET) is recommended in paediatric peritoneal dialysis (PD) patients to assist prescription management. Despite contradictory reports, high transporter status is associated with reduced survival rate in adults. Since cardiac disease is one of the main causes of mortality in paediatric PD patients, we aimed to evaluate whether transport features have any effect on biochemical data and cardiac function in this group. METHODS One hundred and ten PD patients (13 +/- 5 years, PD vintage: 31 +/- 27 months) were enrolled into the study. Four-hour dialysate/plasma creatinine ratio was used for differentiating PET groups. Thirty-eight patients were high transporters, 29 were high-average transporters and 43 were low-average/low transporters. Echocardiography was performed in all subjects. RESULTS Age, PD vintage, dialysate glucose concentration, ultrafiltration volume, urine volume and blood pressure levels were similar in all PET groups. No biochemical or echocardiographic data (ejection fraction, fractional shortening, left ventricular mass index, myocardial performance index, power Doppler E/tissue Doppler E ratio reflecting diastolic function) were different among PET groups except lower albumin (P = 0.025) levels in high transporters and higher high-sensitivity C-reactive protein (P = 0.026) levels in high and high-average transporters compared to other transport groups. CONCLUSIONS Cardiac structural and functional abnormalities are highly prevalent among paediatric PD patients. Transport rates did not have a significant effect on biochemical parameters or cardiac structural/functional parameters. It might be suggested that being a high transporter does not provide a disadvantage in terms of atherogenic tendency and cardiac disease in paediatric PD patients. Oligoanuria, anaemia and hypertension were independent predictors of cardiac disease.
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Moraes TP, Pecoits–Filho R, Ribeiro SC, Rigo M, Silva MM, Teixeira PS, Pasqual DD, Fuerbringer R, Riella MC. Peritoneal Dialysis in Brazil: Twenty-Five Years of Experience in a Single Center. Perit Dial Int 2009. [DOI: 10.1177/089686080902900503] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives To evaluate patient and technique survival and to provide an analysis of peritoneal dialysis (PD)-related peritonitis in 25 years of experience in a single center. Study Design Retrospective study of incident patients on PD from July 1980 to July 2005. Setting Single, university based, Brazilian dialysis program. Patients 680 patients were analyzed in our study from July 1980 to July 2005, with a cumulative experience of 15303 patient-months. All patients over 15 years of age entering the dialysis program were included in the study. Patients with less than 30 days of follow-up were excluded. Biochemical and demographic variables, peritonitis episodes, and patient and technique survival were analyzed. Results Mean age at start of PD was 53 ± 16 years; diabetic nephropathy was the main cause of chronic kidney disease. Cardiovascular disease was the main cause of death (44%); peritonitis was responsible for 16% of fatal events. The predictors of death in our study were diabetes [relative risk (RR) 1.23, p < 0.01], advanced age (RR 1.58, p < 0.001), low serum albumin level (RR 1.25, p < 0.01), and low serum phosphate level (RR 1.39, p < 0.001) upon starting PD. There were 1048 cases of peritonitis over the 25-year period, with a significant reduction in incidence after the introduction of the double-bag system. The number of incident PD patients originating from hemodialysis increased threefold over the observation period ( p < 0.001), with a similar increase in comorbidities over time. Conclusion In the largest single-center report of PD experience in Latin America, we describe the overall rate and trends over time of peritonitis as well as patient and technique survival, which are similar to previous reports. Significant changes in peritonitis rates and causative organisms as well as a significant time-dependent increase in high-risk patients starting PD were observed.
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Affiliation(s)
| | - Roberto Pecoits–Filho
- Pro-Renal Kidney Foundation, Curitiba, Brazil
- Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | | | - Mariane Rigo
- Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Margarete M. Silva
- Pro-Renal Kidney Foundation, Curitiba, Brazil
- Nephrology Division, Hospital Universitário Evangélico de Curitiba, Curitiba, Brazil
| | | | | | | | - Miguel C. Riella
- Pro-Renal Kidney Foundation, Curitiba, Brazil
- Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
- Nephrology Division, Hospital Universitário Evangélico de Curitiba, Curitiba, Brazil
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Hasegawa T, Yoshimura A, Hirose M, Komukai D, Tayama H, Watanabe S, Koiwa F, Yamazaki S, Ideura T. A Strict Low Protein Diet during the Predialysis Period Suppresses Peritoneal Permeability at Induction of Peritoneal Dialysis. Perit Dial Int 2009. [DOI: 10.1177/089686080902900317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The factors that predict baseline peritoneal permeability remain largely unknown. We noticed that patients that adhered to a strict low protein diet (LPD) during the predialysis period seldom showed high peritoneal permeability on the peritoneal equilibration test (PET) at the introduction of peritoneal dialysis (PD). Therefore, we investigated whether a strict LPD during the predialysis period affects peritoneal permeability. Method We retrospectively analyzed 37 patients that started PD in a single Japanese center. Patients were divided into group A and group B by the median amount of daily protein intake (PI) during the predialysis period using urine collected over 24 hours. Results There were no differences between groups A and B in age, gender, proportion of diabetic nephropathy, blood pressure, body mass index, or body surface area. There were also no differences between the groups in laboratory findings, including hematocrit, serum albumin, and serum creatinine. The PETs showed a significantly lower dialysate-to-plasma ratio of creatinine at 4 hours (Cr D/P) for group A than for group B ( p = 0.02). Furthermore, a significant positive correlation between Cr D/P and PI was observed ( r = 0.53, p < 0.01). Conclusion It is suggested that a strict LPD during the predialysis period may suppress peritoneal permeability at induction of PD.
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Affiliation(s)
- Takeshi Hasegawa
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama
- Department of Epidemiology and Healthcare Research, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Ashio Yoshimura
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama
| | - Makoto Hirose
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama
| | - Daisuke Komukai
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama
| | - Hironori Tayama
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama
| | - Susumu Watanabe
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama
| | - Fumihiko Koiwa
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama
| | - Shin Yamazaki
- Department of Epidemiology and Healthcare Research, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Terukuni Ideura
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama
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Affiliation(s)
- Jeffrey Perl
- Division of Nephrology University Health Network Toronto, Ontario, Canada
| | - Joanne M. Bargman
- Division of Nephrology University Health Network Toronto, Ontario, Canada
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Pajek J, Gucek A, Kveder R, Bucar-Pajek M, Kaplan-Pavlovcic S, Bren AF. Impact of dialysis duration and glucose absorption on nutritional indices in stable continuous ambulatory peritoneal dialysis patients. J Ren Nutr 2009; 18:503-8. [PMID: 18940653 DOI: 10.1053/j.jrn.2008.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The presence of comorbidity is a risk factor for both poor nutrition and poor outcome in continuous ambulatory peritoneal dialysis (CAPD) patients. In CAPD specifically, peritoneal glucose load is associated with a possible suppression of appetite, contributing to protein malnutrition. This study sought to explore the factors associated with malnutrition indices in stable peritoneal dialysis patients without significant comorbidity, and to assess the impact of peritoneal glucose absorption on nutrition parameters. DESIGN This was a cross-sectional observational study. SETTING This study took place in the peritoneal dialysis department of a university hospital, and involved outpatients. PATIENTS There were 23 stable, comorbidity-free CAPD patients (9 women), aged 54 +/- 12 years, with a CAPD duration of 28 +/- 25 months (values are mean +/- SD unless otherwise noted). METHODS Nutritional status was evaluated by means of anthropometric and serum measurements. A peritoneal equilibration test was performed, and daily glucose absorption was measured. Lean body mass (LBM) was assessed through creatinine kinetics. RESULTS A significant impact of CAPD duration was found. Patients in the upper quartile of CAPD duration had worse nutritional parameters compared with the rest of the group: their mid-upper-arm surface area and fat surface area were lower (65 +/- 9 cm(2) vs. 78 +/- 6.2 cm(2) and 16 +/- 5.3 cm(2) vs. 26 +/- 9.5 cm(2), respectively, P < .05), their albumin concentration was lower (36 +/- 0.5 g/L vs. 42 +/- 4 g/L, P < .05), and their cholesterol and triglycerides were lower (3.5 +/- 0.5 vs. 5.2 +/- 1 mmol/L and 1.3 +/- 0.6 vs. 2.3 +/- 1.1 mmol/L, respectively, P < .05). No significant correlations between peritoneal glucose absorption and these indices were found. CONCLUSION The duration of dialysis treatment, but not peritoneal glucose absorption, is a predictor of malnutrition in stable, comorbidity-free CAPD patients.
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Affiliation(s)
- Jernej Pajek
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia.
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Cueto–Manzano AM. Rapid Solute Transport in the Peritoneum: Physiologic and Clinical Consequences. Perit Dial Int 2009. [DOI: 10.1177/089686080902902s17] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This review focuses on the physiologic and clinical consequences of rapid solute transport in the peritoneum. The concept, the current understanding of related factors, and the possible causes implicated in rapid solute transport are discussed first. Then, the consequences, with particular emphasis on mortality, are highlighted. Finally, based on recent advances and clinical studies, some strategies for the treatment of fast peritoneal transport are reviewed.
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Affiliation(s)
- Alfonso M. Cueto–Manzano
- Unidad de Investigatión Médica en Enfermedades Renales, UMAE Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico
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Dong J, Li YJ, Lu XH, Gan HP, Zuo L, Wang HY. Correlations of lean body mass with nutritional indicators and mortality in patients on peritoneal dialysis. Kidney Int 2007; 73:334-40. [PMID: 18033246 DOI: 10.1038/sj.ki.5002644] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Detection of malnutrition in dialysis patients is important since this is a predictor of morbidity and mortality. Lean body mass (LBM) reflects the somatic protein store and this was measured by creatinine kinetics, anthropometry, and biometric impedance in 210 incident Chinese patients on continuous ambulatory peritoneal dialysis. The study was started in the third month of dialysis and the patients were followed for an average of 29 months. We devised three models of survival by combining the three different LBM measures with several nutritional markers and recognized outcome predictors. Follow-up was censored for transplantation or transfer to hemodialysis with an end point of death while on peritoneal dialysis. Statistical correlations were observed among the LBM values determined by all the three methods and these correlated significantly with both left and right hand grip strength but not with nutritional markers. LBM by creatinine kinetics, mean arterial pressure, and the calcium-phosphorus product were significant, independent predictors of death in one survival model. Anthropometry and bioelectric impedance were not significant predictors of death in the other two models. Our study suggests that LBM measured by creatinine kinetics, anthropometry, and bioelectrical impedance correlates well with the somatic protein store but not with the general nutritional status.
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Affiliation(s)
- J Dong
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, PR China
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Chung SH, Heimbürger O, Lindholm B. Editorial: Poor Outcomes for Fast Transporters on PD: The Rise and Fall of a Clinical Concern. Semin Dial 2007; 21:7-10. [DOI: 10.1111/j.1525-139x.2007.00327.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Pérez-Fontán M, Rodríguez-Carmona A. Comparing Capd and Automated Peritoneal Dialysis: Where do Solute Transport Issues Stand? Perit Dial Int 2007. [DOI: 10.1177/089686080702700212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Sezer S, Elsurer R, Afsar B, Arat Z, Ozdemir NF, Haberal M. Peritoneal Small Solute Transport Rate Is Related to the Malnutrition Inflammation Score in Peritoneal Dialysis Patients. ACTA ACUST UNITED AC 2007; 107:c156-62. [DOI: 10.1159/000110051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Accepted: 05/16/2007] [Indexed: 11/19/2022]
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Rumpsfeld M, McDonald SP, Johnson DW. Higher peritoneal transport status is associated with higher mortality and technique failure in the Australian and New Zealand peritoneal dialysis patient populations. J Am Soc Nephrol 2005; 17:271-8. [PMID: 16306167 DOI: 10.1681/asn.2005050566] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Although early studies observed that peritoneal membrane transport characteristics were determinants of morbidity and mortality in peritoneal dialysis (PD) patients, more recent investigations, such as the Ademex trial, have refuted these findings. The aim of this study was to determine whether baseline peritoneal transport status predicted subsequent survival in Australian and New Zealand PD patients. The study included all adult patients in Australia and New Zealand who commenced PD between April 1, 1999, and March 31, 2004, and had a peritoneal equilibration test (PET) performed within 6 mo of PD commencement. Times to death and death-censored technique failure were examined by Kaplan-Meier analyses and multivariate Cox proportional hazards models. PET measurements were available in 3702 (72%) of the 5170 individuals who began PD treatment in Australia or New Zealand during the study period. In these patients, high transporter status was found to be a significant, independent predictor of death-censored technique failure (adjusted hazard ratio [AHR] 1.23; 95% confidence interval [CI] 1.02 to 1.49; P = 0.03) and mortality (AHR 1.34; 95% CI 1.05 to 1.79, P = 0.02) compared with low-average transport status. High-average transport class was also associated with mortality (AHR 1.21; 95% CI 1.00 to 1.48; P = 0.047) but not death-censored technique failure (AHR 1.04; 95% CI 0.90 to 1.21) compared with low-average transport status. When transport status was alternatively analyzed as a continuous variable, dialysate:plasma creatinine ratio at 4 h was independently predictive of both death-censored technique failure (AHR 1.07; 95% CI 1.01 to 1.295; P = 0.031) and death (AHR 1.09; 95% CI 1.01 to 1.373; P = 0.036 per 0.1 change in dialysate:plasma creatinine). Peritoneal transport rate is a highly significant risk factor for both mortality and death-censored technique failure in the Australian and New Zealand incident PD patient populations.
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Affiliation(s)
- Markus Rumpsfeld
- Department of Renal Medicine, Level 2, Ambulatory Renal and Transplant Services Building, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane Qld 4102, Australia
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Sezer S, Tutal E, Arat Z, Akçay A, Celik H, Ozdemir FN, Haberal M. Peritoneal Transport Status Influence on Atherosclerosis/Inflammation in CAPD Patients. J Ren Nutr 2005; 15:427-34. [PMID: 16198934 DOI: 10.1053/j.jrn.2005.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2005] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Peritoneal transport status is one of the main determinants of dialysis adequacy and dialysis-related complications in end-stage renal disease patients receiving continuous ambulatory peritoneal dialysis (CAPD). In this study we aimed to investigate the relationship between peritoneal transport characteristics and known promoters of atherosclerosis in a group of patients receiving CAPD for a minimum of 36 months. DESIGN AND PARTICIPANTS We performed a cross-sectional study of a cohort of 84 patients with end-stage renal disease (37 men, 47 women; age, 44.0 +/- 15.7 years; dialysis duration, 40.3 +/- 8.1 months) who were receiving CAPD for minimum 36 months. Peritoneal transport characteristics were identified after a peritoneal equilibration test (PET) determined at the third month of CAPD using Dialysate/Plasma (D/P) reference values. Patients were classified according to one of four peritoneal transport types: high (H), high-average (HA), low-average (LA), and low (L). After PET, patients were grouped as high (H/HA group, n = 51) or low (L/LA group, n = 33) transporters. The patient groups' clinical and laboratory data before dialysis and after initiation of the CAPD were collected retrospectively. The patients' follow-up data were retrieved for the diagnosis of any atherosclerosis-related event after the initiation of CAPD. The following events were collected, including myocardial infarction, having been diagnosed as having coronary artery disease by angiography or myocardium scintigraphy, cerebrovascular accident, and development of clinically evident peripheral arterial disease. RESULTS A comparison of follow-up data revealed that the H/HA transport characteristic was associated with lower albumin (P < .01), higher C-reactive protein (CRP) (P < .0001) levels, and higher recombinant human erythropoietin (rHuEPO) needs (P < .001) when compared with the L/LA type. During follow-up, 28 patients showed an atherosclerosis-related event. Twenty-two of these were in the H/HA group (43.1%), whereas only six were in the L/LA group (18.1%, P < .01). Reanalysis of 18 patients with atherosclerosis-related events and high CRP levels (> 10 mg/L) showed that 15 were in the H/HA and 3 were in the L/LA group. Sixty-eight percent of the H/HA patients with atherosclerosis and 50% of the L/LA patients with an atherosclerotic event also had chronic inflammation (P < .001). A Pearson correlation analysis showed that there was a positive correlation between D/P creatinine levels and 36-month mean CRP levels (r = 0.608, P < .0001), and a negative correlation between D/P creatinine levels and 36-month mean albumin levels (r = -0.299, P < .005). CONCLUSIONS This study shows that the high transporter peritoneal membrane characteristic is a risk factor for inflammatory state in patients with end-stage renal disease. High-transporter patients are at an increased risk of atherosclerosis when compared with their low-transporter counterparts through chronic inflammation.
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Affiliation(s)
- Siren Sezer
- Department of Nephrology, Baskent University Hospital, Ankara, Turkey
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Krieter DH, Collins G, Summerton J, Spence E, Moragues HL, Canaud B. Mid-dilution on-line haemodiafiltration in a standard dialyser configuration. Nephrol Dial Transplant 2004; 20:155-60. [PMID: 15522903 DOI: 10.1093/ndt/gfh520] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mid-dilution haemodiafiltration (HDF) results in an improved middle molecule removal compared with standard HDF. The OLpur MD 190 haemodiafilter represents a new dialyser design exclusively for mid-dilution on-line HDF. Compared with standard haemodialysers, structural changes in the headers allow the infusion of high replacement fluid volumes after a first post-dilution and before a second pre-dilution stage. METHODS We compared in vitro the new device [blood flow (QB) 400 ml/min, substitution flow (QS) 100 and 200 ml/min, dialysate flow (QD) 800 ml/min] with a conventional high-flux dialyser of the same surface area in haemodialysis (HD) (QD 500 ml/min) and post-dilution HDF (at QS 60, QD = 500 ml/min and at QS 100, QD = 800 ml/min) modes. Subsequently, we performed an initial clinical application of the new device in six mid-dilution HDF treatments of five end-stage renal disease patients (QB 400 ml/min, QS 200 ml/min, QD 800 ml/min, treatment duration 205+/-23 min). RESULTS In vitro urea and beta2-microglobulin clearances in mid-dilution HDF were, respectively, 309.2+/-5.5 and 144.4+/-15.2 ml/min (QS 100) and 321.6+/-4.1 and 204.9+/-4.1 ml/min (QS 200), compared with 278.6+/- 17.2 and 94.0+/-7.6 ml/min in HD, and 310.8+/-10.2 and 123.0+/-6.5 ml/min (QS 60) and 323.6+/-11.2 and 158.0+/-10.3 ml/min (QS 100) in post-dilution HDF. The in vivo trials showed the clinical utility of the device and confirmed the in vitro data: urea and beta2-microglobulin clearances were, respectively, 324.6+/- 10.9 and 207.9+/-29.3 ml/min, while reduction ratios were 75.0+/-5.5 and 83.6+/-4.7%. CONCLUSION Our preliminary results need confirmation in a prospective cross-over study. However, the Nephros MD 190 haemodiafilter promises to be a true technological step ahead in terms of improved beta2-microglobulin removal.
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Mehrotra R, Kopple JD. Protein and energy nutrition among adult patients treated with chronic peritoneal dialysis. ACTA ACUST UNITED AC 2003; 10:194-212. [PMID: 14708073 DOI: 10.1053/j.arrt.2003.08.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Protein-energy malnutrition (PEM) in adult patients treated with chronic peritoneal dialysis (CPD), which is highly prevalent and frequently severe in its manifestation, poses a significant therapeutic dilemma. The causes of PEM include inflammation, low nutrient intake, nutrient losses during dialysis, metabolic acidemia, coexisting illnesses, and possibly the endocrine disorders of uremia. Treatment strategies for PEM in CPD patients include the following: attempt to treat the potentially reversible causes of anorexia, increase nutrient intake (by nutritional counseling, oral food supplements, consideration of appetite stimulants and intraperitonial amino acid solutions), and the correction of metabolic acidosis. Coexisting illnesses engendering PEM should be treated. Experimental evidence suggests that such agents as anabolic steroids, human growth hormone, insulin-like growth factor-I, and L-carnitine may engender positive protein balance in these individuals. Finally, the use of anti-inflammatory agents to improve the nutritional status of malnourished CPD patients remains to be defined. There is a need to carry out clinical trials that examine whether an improvement in the nutritional status of CPD patients is associated with an improvement in their mortality, morbidity and/or quality of life.
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Affiliation(s)
- Rajnish Mehrotra
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA 90502, USA.
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40
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Krieter DH, Canaud B. High permeability of dialysis membranes: what is the limit of albumin loss? Nephrol Dial Transplant 2003; 18:651-4. [PMID: 12637630 DOI: 10.1093/ndt/gfg054] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Szeto CC, Wong TYH, Chow KM, Leung CB, Li PKT. Dialysis adequacy and transport test for characterization of peritoneal transport type in Chinese peritoneal dialysis patients receiving three daily exchanges. Am J Kidney Dis 2002; 39:1287-99. [PMID: 12046043 DOI: 10.1053/ajkd.2002.33405] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Dialysis adequacy and transport test (DATT) is an accurate method to classify peritoneal transport type for continuous ambulatory peritoneal dialysis (CAPD) patients with a regimen of four exchanges of 2 L/d. We examined the accuracy of DATT for the characterization of peritoneal transport type in patients with a regimen of three exchanges of 2 L/d, which is the standard CAPD regimen in Hong Kong Chinese. We studied 189 adult Chinese CAPD patients with a prescription of three exchanges of 2 L/d. Patients who had a peritonitis episode within the previous 30 days were excluded. Standard peritoneal equilibration test (PET) and DATT were performed on consecutive days. Correlation coefficients between dialysate-to-plasma ratios of creatinine (D/P) obtained for the PET and the DATT was 0.698 (P < 0.001). Peritoneal transport type was classified according to the reported D/P creatinine reference values obtained from the PET at 4 hours. When the result was compared with the transport type classified by the DATT result using the linear regression formula derived, the Cohen kappa was 0.433 (95% confidence interval, 0.329 to 0.537), which could be regarded as a moderate level of agreement. For classification of the low transporters, the specificity of DATT was 90.1%, and sensitivity was 72.3%. For classification of the high transporters, the specificity of DATT was 96.6%, and sensitivity was 57.1%. DATT and PET had a reasonable agreement in the classification of peritoneal transport type for Chinese CAPD patients receiving a daily schedule of three exchanges of 2 L/d. Although DATT may be less accurate for CAPD patients with three daily exchanges, it remains a specific method to identify low and high transporters.
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China.
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Passlick-Deetjen J, Quellhorst E. Continuous flow peritoneal dialysis (CFPD): a glimpse into the future. Nephrol Dial Transplant 2001; 16:2296-9. [PMID: 11733618 DOI: 10.1093/ndt/16.12.2296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Recent studies have shown that patients with high peritoneal transport characteristics have substantially increased morbidity and mortality. This finding is counter-intuitive, since HTs will a priori achieve higher clearances. There are many possible causes: increased protein losses with consequent hypoalbuminemia; poor ultrafiltration capacity causing fluid retention, ventricular hypertrophy and hypertension; increased glucose absorption leading to anorexia, hyperinsulinism, and local AGE formation; and the development of an atherogenic lipid profile. While common pathogenic causes of high peritoneal transport and atherosclerosis have been hypothesized, it is more likely that CAPD as currently practiced is unsuitable for HTs, who should be switched to HD or NIPD. Renal and peritoneal clearances have different clinical effects and should be assessed separately. Current measures of dialysis adequacy, such as total Kt/V, do not therefore describe the patient's clinical situation accurately and are insufficient.
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Affiliation(s)
- J Heaf
- Department of Nephrology B, Copenhagen University Hospital, Herlev, Denmark.
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Sherman RA. Briefly Noted. Semin Dial 2000. [DOI: 10.1046/j.1525-139x.2000.00020.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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