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Chen JHC, Johnson DW, Cho Y, Cheetham M, Sud K, Hayat A, Stallard B, Clayton P, Davies CE, Borlace M, Boudville N. Associations of neutral pH, low-GDP peritoneal dialysis solutions with patient survival, transfer to haemodialysis and peritonitis. Nephrol Dial Transplant 2024; 39:222-232. [PMID: 37429598 PMCID: PMC10828214 DOI: 10.1093/ndt/gfad153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Peritoneal dialysis (PD) solutions containing low levels of glucose degradation products (GDPs) are associated with attenuation of peritoneal membrane injury and vascular complications. However, clinical benefits associated with neutral-pH, low-GDP (N-pH/L-GDP) solutions remain unclear. METHODS Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the associations between N-pH/L-GDP solutions and all-cause mortality, cause-specific mortality, transfer to haemodialysis (HD) for ≥30 days and PD peritonitis in adult incident PD patients in Australia and New Zealand between 1 January 2005 and 31 December 2020 using adjusted Cox regression analyses. RESULTS Of 12 814 incident PD patients, 2282 (18%) were on N-pH/L-GDP solutions. The proportion of patients on N-pH/L-GDP solutions each year increased from 11% in 2005 to 33% in 2017. During the study period, 5330 (42%) patients died, 4977 (39%) experienced transfer to HD and 5502 (43%) experienced PD peritonitis. Compared with the use of conventional solutions only, the use of any form of N-pH/L-GDP solution was associated with reduced risks of all-cause mortality {adjusted hazard ratio [aHR] 0.67 [95% confidence interval (CI) 0.61-0.74]}, cardiovascular mortality [aHR 0.65 (95% CI 0.56-0.77)], infection-related mortality [aHR 0.62 (95% CI 0.47-0.83)] and transfer to HD [aHR 0.79 (95% CI 0.72-0.86)] but an increased risk of PD peritonitis [aHR 1.16 (95% CI 1.07-1.26)]. CONCLUSIONS Patients who received N-pH/L-GDP solutions had decreased risks of all-cause and cause-specific mortality despite an increased risk of PD peritonitis. Studies assessing the causal relationships are warranted to determine the clinical benefits of N-pH/L-GDP solutions.
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Affiliation(s)
- Jenny H C Chen
- Department of Renal Medicine, Wollongong Hospital, Wollongong, NSW, Australia
- School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - David W Johnson
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, University of Queensland, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Brisbane, QLD, Australia
| | - Yeoungjee Cho
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Brisbane, QLD, Australia
| | - Melissa Cheetham
- Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
- Sunshine Coast Health Institute, Birtinya, QLD, Australia
| | - Kamal Sud
- Nepean Kidney Research Centre, Department of Renal Medicine, Nepean Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Ashik Hayat
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Brisbane, QLD, Australia
| | - Belinda Stallard
- Department of Nephrology, Tweed Hospital, Tweed Heads, NSW, Australia
| | - Philip Clayton
- Department of Nephrology, Royal Adelaide Hospital, Adelaide, SA, Australia
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Christopher E Davies
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Monique Borlace
- Department of Nephrology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Neil Boudville
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
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2
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How to Improve the Biocompatibility of Peritoneal Dialysis Solutions (without Jeopardizing the Patient's Health). Int J Mol Sci 2021; 22:ijms22157955. [PMID: 34360717 PMCID: PMC8347640 DOI: 10.3390/ijms22157955] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/21/2021] [Accepted: 07/24/2021] [Indexed: 12/23/2022] Open
Abstract
Peritoneal dialysis (PD) is an important, if underprescribed, modality for the treatment of patients with end-stage kidney disease. Among the barriers to its wider use are the deleterious effects of currently commercially available glucose-based PD solutions on the morphological integrity and function of the peritoneal membrane due to fibrosis. This is primarily driven by hyperglycaemia due to its effects, through multiple cytokine and transcription factor signalling-and their metabolic sequelae-on the synthesis of collagen and other extracellular membrane components. In this review, we outline these interactions and explore how novel PD solution formulations are aimed at utilizing this knowledge to minimise the complications associated with fibrosis, while maintaining adequate rates of ultrafiltration across the peritoneal membrane and preservation of patient urinary volumes. We discuss the development of a new generation of reduced-glucose PD solutions that employ a variety of osmotically active constituents and highlight the biochemical rationale underlying optimization of oxidative metabolism within the peritoneal membrane. They are aimed at achieving optimal clinical outcomes and improving the whole-body metabolic profile of patients, particularly those who are glucose-intolerant, insulin-resistant, or diabetic, and for whom daily exposure to high doses of glucose is contraindicated.
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3
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Huang CC, Cheng KF, Wu HDI. Survival Analysis: Comparing Peritoneal Dialysis and Hemodialysis in Taiwan. Perit Dial Int 2020. [DOI: 10.1177/089686080802803s04] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
⋄ Objectives Comparisons of survival in patients on peritoneal dialysis (PD) and on hemodialysis (HD) have been conducted in many Western countries, but publications on this subject in Asian populations are scarce. The present study estimated the survival and the relative mortality hazard for HD and PD patients in Taiwan. ⋄ Methods Incident end-stage renal disease patients reported to the Taiwan Renal Registry during 1995 – 2002 were included in the study. Patients had to be 20 years of age or older and had to have survived for the first 90 days on dialysis. A total of 45 820 incident HD and 2809 incident PD patients formed the study population. Patients on PD were treated mainly with traditional glucose-based solutions. Using an intent-to-treat analysis, the Cox proportional hazards (CPH) model was applied to identify the factors that predict survival by treatment modality. Subgroup analyses were conducted by stratifying patients according to sex, comorbidity, age, and diabetes status. Kaplan–Meier estimates were used to explore the survival of HD and PD patients. Adjustments were implemented using the CPH model. ⋄ Results The overall 1-year, 2-year, 3-year, 5-year and 10-year survival rates for PD patients were 89.8%, 77.6%, 67.6%, 55.5%, and 35% respectively. The equivalent survival rates for HD patients were 87.5%, 76.6%, 68.1%, 54.3%, and 33.8%. The differences were not statistically significant ( p = 0.125). The CPH analysis stratified by diabetes status and age revealed that PD patients 55 years of age or younger and nondiabetic had a lower mortality ratio (MR) of 0.94. But the MR increased to 1.31 for nondiabetic patients older than 55. The MR for PD versus HD further increased to 1.72 for diabetic patients 55 years of age or younger, and to 1.99 for diabetic patients older than 55. ⋄ Conclusions After adjusting for both demographic and clinical case-mix differences, PD and HD patients were observed to have similar long-term survival. Subgroup analyses revealed that, among diabetic patients and patients older than 55, those on HD experienced better survival than did those on PD.
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Han SH, Lee JE, Kim DK, Moon SJ, Kim HW, Chang JH, Kim BS, Kang SW, Choi KH, Lee HY, Han DS. Long-Term Clinical Outcomes of Peritoneal Dialysis Patients: Single Center Experience from Korea. Perit Dial Int 2020. [DOI: 10.1177/089686080802803s05] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Of a large body of literature reporting clinical outcomes for patients maintained on peritoneal dialysis (PD), most publications have focused on relatively short-term results. Few reports have focused on long-term survival in PD patients. Here, we present our experience with long-term patient outcomes and further analyses of the trends in demographics and clinical outcomes of 2301 end-stage renal disease (ESRD) patients treated with continuous ambulatory PD (CAPD) during a 25-year period (1981 – 2005) at our institute. Outcomes were analyzed for 1656 patients, excluding those younger than 15 years of age at initiation of CAPD, those having less than 3 months’ follow-up, or those who had been on hemodialysis or who received a kidney graft before starting CAPD. In the study patients, technique survival at 5 and 10 years was 71.9% and 48.1% respectively. Patient survival was 69.8% and 51.8%. Mean age at the start of PD (50.4 ± 13.9 years vs. 44.2 ± 13.9 years, p < 0.01), ESRD incidence as a result of diabetic nephropathy (30.5% vs. 19.5%, p < 0.01), and incidence of cardiovascular comorbidities (26.6% vs. 20.5%, p < 0.01) were all significantly greater in patients who started PD during the second half of the study period (1993 – 2005) as compared with the first half (1981 – 1992). A multivariate analysis adjusting for these changes in demographics and comorbid conditions revealed that PD therapy starting in 1993 – 2005 was associated with a significant reduction in technique failure [hazard ratio (HR): 0.65; p < 0.01] and mortality (HR: 0.68; p < 0.01) as compared with the earlier period. However, in subgroup analyses, technique survival was not observed to be significantly improved in patients with diabetes. In summary, technique and patient survival have significantly improved despite increases in patient age, cardiovascular comorbidity, and ESRD caused by diabetes. Although diabetes, older age, and cardiovascular comorbidities are not factors that are easily modifiable to improve PD outcomes, results at our institution are encouraging in an era of declining PD utilization.
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Affiliation(s)
- Seung Hyeok Han
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Eun Lee
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Jin Moon
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun-Wook Kim
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Chang
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Beom Seok Kim
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Yung Lee
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Suk Han
- Department of Internal Medicine, The Institute of Kidney Disease, Yonsei University College of Medicine, Seoul, Korea
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Kim YL. Can we Overcome the Predestined Poor Survival of Diabetic Patients? Perspectives from Pre- and Post-Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080702702s29] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Although the survival of diabetic peritoneal dialysis (PD) patients has improved, it is still much worse than the survival of nondiabetic patients. Diabetes has its own risks for cardiovascular disease (CVD), such as increased levels of advanced glycation end-products, carbonyl and oxidative stress, and low-grade inflammation. An independent, graded association has been observed between a reduced glomerular filtration rate and the risk of CVD events in chronic kidney disease (CKD). Both CKD and diabetes synergistically lead to a high risk of CVD. It seems that the poor survival of diabetic PD patients is predestined at the initiation of dialysis because of multiple pre-existing risk factors and comorbid diseases, particularly CVD. Recently, several trials were successful in improving the survival of patients with diabetic CKD. Tight control of glucose, blood pressure management using angiotensin converting-enzyme inhibitors or angiotensin II receptor blockers, and use of statins, antioxidants, or peroxisome proliferator-activated receptor gamma agonists may improve the survival of diabetic PD patients. However, simple correction of a single CVD risk factor is not likely to be effective. New PD solutions such as those low in glucose degradation products or those with icodextrin may also be effective in reducing the risk of CVD in diabetic PD patients. Therefore, multifactorial interventions—including diet control, early referral, and choice of an optimal PD solution—may improve the survival of diabetic PD patients.
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Affiliation(s)
- Yong-Lim Kim
- Division of Nephrology and Department of Internal Medicine, Department of Biochemistry and Cell Biology, Kyungpook National University School of Medicine, Daegu, Korea
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6
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Tomo T. Peritoneal Dialysis Solutions Low in Glucose Degradation Products—evidence for Clinical Benefits. Perit Dial Int 2020. [DOI: 10.1177/089686080802803s23] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In Japan, two types of new peritoneal dialysis fluid (PDF) are ordinarily used: two-chambered PDF, and icodextrin PDF. Two-chambered PDF has several biocompatible characteristics, one being low glucose degradation products (GDPs). Of the several GDPs in PDF, 3,4-dideoxyglucosone-3-ene (3,4-DGE) is thought to be strongly associated with the cytotoxicity of standard PDF. Using a PDF low in GDPs may reduce exposure of the peritoneum to 3,4-DGE, helping to preserve peritoneal function in PD patients. Additionally, use of a PDF low in GDPs may reduce plasma levels of advanced glycosylation end-products in PD patients, a change that may help to preserve vascular function in PD patients. Peritoneal rest for 24 hours after exposure to a PDF with low GDPs improves the activity of human peritoneal mesothelial cells. As compared with the use of standard PDF, the use of low-GDP PDF in combination therapy (peritoneal dialysis plus hemodialysis) may more effectively preserve peritoneal function. The new PDF low in GDPs has bio-compatible characteristics relative to peritoneum and system that may help to preserve peritoneal function or reduce complications such as atherosclerosis or dialysis-related amyloidosis in dialysis patients.
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Affiliation(s)
- Tadashi Tomo
- Faculty of Medicine, Second Department of Internal Medicine, Oita University, Yufu, Japan
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7
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Erixon M, Wieslander A, Lindén T, Carlsson O, Jönsson JÅ, Simonsen O, Kjellstrand P. 3,4-DGE in Peritoneal Dialysis Fluids Cannot be Found in Plasma after Infusion into the Peritoneal Cavity. Perit Dial Int 2020. [DOI: 10.1177/089686080802800315] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
ObjectiveGlucose degradation products (GDPs) are important in the outcome of peritoneal dialysis (PD) treatment. 3,4-dideoxyglucosone-3-ene (3,4-DGE) is the most cytotoxic GDP found in conventionally manufactured fluids and may, in addition, be recruited from 3-deoxyglucosone (3-DG). It is not known what happens with those GDPs in patients during PD. The aim of this study was to investigate if the 3,4-DGE and 3-DG in PD fluids can be found in plasma during treatment.DesignPD patients were dialyzed with a conventional PD fluid containing 43 μmol/L 3,4-DGE and 281 μmol/L 3-DG. Parallel experiments were performed in rats as well as in vitro with human plasma. The rats were dialyzed with a PD fluid containing 100 μmol/L 3,4-DGE and 200 μmol/L 3-DG.ResultsThe concentration of 3,4-DGE in the peritoneum decreased at a much higher rate than 3-DG during the dwell. 3,4-DGE was not, however, detected in the plasma of patients or rats during dialysis. The concentration of 3-DG in plasma peaked shortly after infusion of the fluid to the peritoneal cavity. The concentration of 3,4-DGE during experimental incubation in plasma decreased rapidly, while the concentration of 3-DG decreased only 10% as rapidly or less.Conclusion3,4-DGE could not be detected in plasma from either PD patients or rats during dialysis. This is presumably due to its high reactivity. 3-DG may, on the other hand, pass through the membrane and be detected in the blood.
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Affiliation(s)
- Martin Erixon
- Gambro AB Lund, Sweden
- Analytical Chemistry, Lund, Sweden
| | | | | | | | | | - Ole Simonsen
- University of Lund; University Hospital of Lund, Lund, Sweden
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8
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Van Laecke S, Veys N, Verbeke F, Vanholder R, Van Biesen W. The Fate of Older Diabetic Patients on Peritoneal Dialysis: Myths and Mysteries and Suggestions for Further Research. Perit Dial Int 2020. [DOI: 10.1177/089686080702700602] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The outcome of older and especially of female diabetic patients appears to be worse on peritoneal dialysis (PD) than on hemodialysis (HD). This opinion is based mostly on data coming from the USA, whereas data from other regions seem to give a more balanced picture. The questions arise whether indeed outcome is worse in this patient group, and what might be the underlying reasons for this; further research to unravel this phenomenon is warranted. This review proposes several suggestions for further exploration. The observed differences in outcome might be attributable to differences in treatment practices and experience with PD versus HD. As cardiovascular mortality is a major killer in end-stage renal disease patients, differences in fluid homeostasis and how it is achieved are potential explanations. Fluid balance is potentially more difficult to obtain in PD patients, especially as in the past it was spuriously suggested that fluid restriction was less important in PD patients. PD and HD might also have different impacts on factors related to inflammation, insulin resistance, and hormone balance. The adipocytokine network is of special interest in this respect. It is also possible that bias introduced by the way we measure body composition might have a more negative impact on PD than on HD patients. Finally, it still is not fully established that if diabetic patients are treated appropriately, their outcome on PD is worse than that on HD; further observational trials in this respect are needed. All these topics require further clarification and investigation.
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Affiliation(s)
- Steven Van Laecke
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium
| | - Nic Veys
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium
| | - Francis Verbeke
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium
| | - Raymond Vanholder
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium
| | - Wim Van Biesen
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Belgium
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Comparative study of peritoneal dialysis versus hemodialysis on the clinical outcomes in Korea: a population-based approach. Sci Rep 2019; 9:5905. [PMID: 30976069 PMCID: PMC6459886 DOI: 10.1038/s41598-019-42508-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 04/02/2019] [Indexed: 12/22/2022] Open
Abstract
There has been paucity of data regarding the secular trend of adverse outcomes in peritoneal dialysis (PD) as compared with hemodialysis (HD) in Korea. 96,596 patients who started dialysis between 2004-2015 in Korea were identified using the National Health Insurance Service database. The adjusted hazard ratio (HR) (95% confidence interval, CI) of PD over HD for mortality was 1.31 (1.27-1.36; P < 0.001) in the period of 2004-2007 and 1.21 (1.16-1.27; P < 0.001) in the period of 2008-2011. However, the hazard of PD over HD for mortality turned out to be insignificant in the period of 2012-2015. Similar trend was noted for nonfatal cardiovascular events (CVEs). In subgroup analysis, the hazard of PD over HD for mortality was evident, regardless of the status of age, diabetes, and comorbidity burden in 2004-2011. In 2012-2015, however, the hazard of PD over HD for mortality was insignificant when follow up was censored at one year, which became significant when follow up follow up was censored at three or five year. In conclusion, the mortality of PD over HD in Korea has been significantly improved, a finding that was paralleled by the improved nonfatal CVEs.
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Misra PS, Nessim SJ, Perl J. "Biocompatible" Neutral pH Low-GDP Peritoneal Dialysis Solutions: Much Ado About Nothing? Semin Dial 2018; 30:164-173. [PMID: 28251697 DOI: 10.1111/sdi.12579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Adverse outcomes in peritoneal dialysis (PD), including PD related infections, the loss of residual kidney function (RKF), and longitudinal, deleterious changes in peritoneal membrane function continue to limit the long-term success of PD therapy. The observation that these deleterious changes occur upon exposure to conventional glucose-based PD solutions fuels the search for a more biocompatible PD solution. The development of a novel PD solution with a neutral pH, and lower in glucose degradation products (GDPs) compared to its conventional predecessors has been labeled a "biocompatible" solution. While considerable evidence in support of these novel solutions' biocompatibility has emerged from cell culture and animal studies, the clinical benefits as compared to conventional PD solutions are less clear. Neutral pH low GDP (NpHLGDP) PD solutions appear to be effective in reducing infusion pain, but their effects on other clinical endpoints including peritoneal membrane function, preservation of RKF, PD-related infections, and technique and patient survival are less clear. The literature is limited by studies characterized by relatively few patients, short follow-up time, heterogeneity with regards to the novel PD solution type under study, and the different patient populations under study. Nonetheless, the search for a more biocompatible PD solution continues with emerging data on promising non glucose-based solutions.
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Affiliation(s)
- Paraish S Misra
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sharon J Nessim
- Division of Nephrology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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11
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Mathew AT, Fishbane S, Obi Y, Kalantar-Zadeh K. Preservation of residual kidney function in hemodialysis patients: reviving an old concept. Kidney Int 2016; 90:262-271. [PMID: 27182000 PMCID: PMC5798008 DOI: 10.1016/j.kint.2016.02.037] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/18/2016] [Accepted: 02/24/2016] [Indexed: 12/30/2022]
Abstract
Residual kidney function (RKF) may confer a variety of benefits to patients on maintenance dialysis. RKF provides continuous clearance of middle molecules and protein-bound solutes. Whereas the definition of RKF varies across studies, interdialytic urine volume may emerge as a pragmatic alternative to more cumbersome calculations. RKF preservation is associated with better patient outcomes including survival and quality of life and is a clinical parameter and research focus in peritoneal dialysis. We propose the following practical considerations to preserve RKF, especially in newly transitioned (incident) hemodialysis patients: (1) periodic monitoring of RKF in hemodialysis patients through urine volume and including residual urea clearance with dialysis adequacy and outcome markers such as anemia, fluid gains, minerals and electrolytes, nutritional, status and quality of life; (2) avoidance of nephrotoxic agents such as radiocontrast dye, nonsteroidal anti-inflammatory drugs, and aminoglycosides; (3) more rigorous hypertension control and minimizing intradialytic hypotensive episodes; (4) individualizing the initial dialysis prescription with consideration of an incremental/infrequent approach to hemodialysis initiation (e.g., twice weekly) or peritoneal dialysis; and (5) considering a lower protein diet, especially on nondialysis days. Because RKF appears to be associated with better patient outcomes, it requires more clinical and research focus in the care of hemodialysis and peritoneal dialysis patients.
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Affiliation(s)
- Anna T Mathew
- Hofstra Northwell School of Medicine, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck, New York, USA
| | - Steven Fishbane
- Hofstra Northwell School of Medicine, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck, New York, USA.
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA; Fielding School of Public Health at UCLA, Los Angeles, California, USA; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California, USA
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12
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Lichodziejewska-Niemierko M, Chmielewski M, Dudziak M, Ryta A, Rutkowski B. Hydration Status of Patients Dialyzed with Biocompatible Peritoneal Dialysis Fluids. Perit Dial Int 2015; 36:257-61. [PMID: 26475845 DOI: 10.3747/pdi.2015.00009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 05/13/2015] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED ♦ BACKGROUND Biocompatible fluids for peritoneal dialysis (PD) have been introduced to improve dialysis and patient outcome in end-stage renal disease. However, their impact on hydration status (HS), residual renal function (RRF), and dialysis adequacy has been a matter of debate. The aim of the study was to evaluate the influence of a biocompatible dialysis fluid on the HS of prevalent PD patients. ♦ METHODS The study population consisted of 18 prevalent PD subjects, treated with standard dialysis fluids. At baseline, 9 patients were switched to a biocompatible solution, low in glucose degradation products (GDPs) (Balance; Fresenius Medical Care, Bad Homburg, Germany). Hydration status was assessed through clinical evaluation, laboratory parameters, echocardiography, and bioimpedance spectroscopy over a 24-month observation period. ♦ RESULTS During the study period, urine volume decreased similarly in both groups. At the end of the evaluation, there were also no differences in clinical (body weight, edema, blood pressure), laboratory (N-terminal pro-brain natriuretic peptide, NTproBNP), or echocardiography determinants of HS. However, dialysis ultrafiltration decreased in the low-GDP group and, at the end of the study, equaled 929 ± 404 mL, compared with 1,317 ± 363 mL in the standard-fluid subjects (p = 0.06). Hydration status assessed by bioimpedance spectroscopy was +3.64 ± 2.08 L in the low-GDP patients and +1.47 ± 1.61 L in the controls (p = 0.03). ♦ CONCLUSIONS The use of a low-GDP biocompatible dialysis fluid was associated with a tendency to overhydration, probably due to diminished ultrafiltration in prevalent PD patients.
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Affiliation(s)
- Monika Lichodziejewska-Niemierko
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Poland Department of Palliative Medicine, Medical University of Gdańsk, Poland
| | - Michał Chmielewski
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Poland
| | - Maria Dudziak
- Department of Noninvasive Cardiac Diagnostics, Medical University of Gdańsk, Poland
| | - Alicja Ryta
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Poland
| | - Bolesław Rutkowski
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Poland
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13
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Bakkaloglu SA, Warady BA. Difficult peritonitis cases in children undergoing chronic peritoneal dialysis: relapsing, repeat, recurrent and zoonotic episodes. Pediatr Nephrol 2015; 30:1397-406. [PMID: 25231680 DOI: 10.1007/s00467-014-2952-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 07/16/2014] [Accepted: 08/26/2014] [Indexed: 12/22/2022]
Abstract
Despite technological improvements in dialysis connectology and dialysis technique, peritonitis remains the most common and most significant complication of peritoneal dialysis (PD) in children. Most children undergoing chronic PD experience none or only one peritonitis episode, while others have multiple episodes or episodes secondary to unusual organisms. Knowledge of potential risk factors and likely patient outcome is imperative if treatment is to be optimized. In this review we will, in turn, describe episodes of peritonitis that are characterized as either relapsing, recurrent, repeat or zoonosis-related to highlight the clinical issues that are commonly encountered by clinicians treating these infections.
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Affiliation(s)
- Sevcan A Bakkaloglu
- Department of Pediatrics, Division of Pediatric Nephrology, Gazi University School of Medicine, Ankara, Turkey,
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Howard K, Hayes A, Cho Y, Cass A, Clarke M, Johnson DW. Economic Evaluation of Neutral-pH, Low–Glucose Degradation Product Peritoneal Dialysis Solutions Compared With Standard Solutions: A Secondary Analysis of the balANZ Trial. Am J Kidney Dis 2015; 65:773-9. [DOI: 10.1053/j.ajkd.2014.12.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 12/26/2014] [Indexed: 11/11/2022]
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Büchel J, Bartosova M, Eich G, Wittenberger T, Klein-Hitpass L, Steppan S, Hackert T, Schaefer F, Passlick-Deetjen J, Schmitt CP. Interference of peritoneal dialysis fluids with cell cycle mechanisms. Perit Dial Int 2014; 35:259-74. [PMID: 25082841 DOI: 10.3747/pdi.2013.00010] [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] [Received: 01/13/2014] [Accepted: 01/28/2014] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Peritoneal dialysis fluids (PDF) differ with respect to osmotic and buffer compound, and pH and glucose degradation products (GDP) content. The impact on peritoneal membrane integrity is still insufficiently described. We assessed global genomic effects of PDF in primary human peritoneal mesothelial cells (PMC) by whole genome analyses, quantitative real-time polymerase chain reaction (RT-PCR) and functional measurements. METHODS PMC isolated from omentum of non-uremic patients were incubated with conventional single chamber PDF (CPDF), lactate- (LPDF), bicarbonate- (BPDF) and bicarbonate/lactate-buffered double-chamber PDF (BLPDF), icodextrin (IPDF) and amino acid PDF (APDF), diluted 1:1 with medium. Affymetrix GeneChip U133Plus2.0 (Affymetrix, CA, USA) and quantitative RT-PCR were applied; cell viability was assessed by proliferation assays. RESULTS The number of differentially expressed genes compared to medium was 464 with APDF, 208 with CPDF, 169 with IPDF, 71 with LPDF, 45 with BPDF and 42 with BLPDF. Out of these genes 74%, 73%, 79%, 72%, 47% and 57% were downregulated. Gene Ontology (GO) term annotations mainly revealed associations with cell cycle (p = 10(-35)), cell division, mitosis, and DNA replication. One hundred and eighteen out of 249 probe sets detecting genes involved in cell cycle/division were suppressed, with APDF-treated PMC being affected the most regarding absolute number and degree, followed by CPDF and IPDF. Bicarbonate-containing PDF and BLPDF-treated PMC were affected the least. Quantitative RT-PCR measurements confirmed microarray findings for key cell cycle genes (CDK1/CCNB1/CCNE2/AURKA/KIF11/KIF14). Suppression was lowest for BPDF and BLPDF, they upregulated CCNE2 and SMC4. All PDF upregulated 3 out of 4 assessed cell cycle repressors (p53/BAX/p21). Cell viability scores confirmed gene expression results, being 79% of medium for LPDF, 101% for BLPDF, 51% for CPDF and 23% for IPDF. Amino acid-containing PDF (84%) incubated cells were as viable as BPDF (86%). CONCLUSION In conclusion, PD solutions substantially differ with regard to their gene regulating profile and impact on vital functions of PMC, i.e. on cells known to be essential for peritoneal membrane homeostasis.
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Affiliation(s)
- Janine Büchel
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Maria Bartosova
- University Hospital for Pediatrics & Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Gwendolyn Eich
- University Hospital for Pediatrics & Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | | | - Ludger Klein-Hitpass
- University of Duisburg-Essen, Faculty of Medicine, Institute of Cell Biology, Essen, Germany
| | - Sonja Steppan
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Franz Schaefer
- University Hospital for Pediatrics & Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | | | - Claus P Schmitt
- University Hospital for Pediatrics & Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
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İnal S, Okyay GU, Ulu MS, Kıdır V, Altuntaş A, Ahsen A, Ünverdi S, Akoğlu H, Yüksel Ş, Duranay M, Sezer MT. The effect of biocompatible peritoneal dialysis solutions on neutrophil to lymphocyte ratio. Ren Fail 2014; 36:1239-43. [PMID: 25009984 DOI: 10.3109/0886022x.2014.937662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Long-term exposure to dialysis solutions is an important contributor to the ongoing inflammatory process in peritoneal dialysis (PD) patients. Some studies have shown amelioration of this adverse effect with biocompatible solutions. We aimed to compare the neutrophil-to-lymphocyte (N/L) ratio in PD patients using biocompatible and standard solutions and to find out the association between N/L ratio and peritonitis indices. MATERIALS AND METHODS This was a cross-sectional, multicenter study involving 120 prevalent PD patients. Seventy-one patients (59%) were using biocompatible solutions and 49 patients (41%) were using standard solutions. From blood samples, N/L ratio and platelet-to-lymphocyte ratio were calculated and mean platelet volume, erythrocyte sedimentation rate and hs-CRP values were detected. Data regarding the peritonitis rate and time to first peritonitis episode were also recorded. RESULTS Biocompatible and standard groups were similar regarding age and gender. N/L ratio and hs-CRP levels have been found significantly higher in patients using biocompatible solutions (3.75 ± 1.50 vs. 3.27 ± 1.3, p = 0.04 and 3.2 ± 2.5 vs. 1.8 ± 2.0, p < 0.01, respectively). Peritonitis rates and time to the first peritonitis episode were found similar in patients using both types of solutions (0.23 ± 0.35 vs. 0.27 ± 0.32, p = 0.36 and 32.8 ± 35.8 vs. 21.5 ± 26.9 months, p = 0.16, respectively). DISCUSSION N/L ratio was significantly higher in biocompatible solution users in parallel to hs-CRP levels, so biocompatible solutions seem to be related with increased inflammation in PD patients. Although we cannot make a certain explanation, we assume that there may be an association between acidity of the peritoneal content and virulence of microorganisms.
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Affiliation(s)
- Salih İnal
- Department of Internal Medicine, Division of Nephrology, Süleyman Demirel University Medical School , Isparta , Turkey
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Figueiredo AE, de Siqueira SL, Poli-de-Figueiredo CE, d'Avila DO. Hand hygiene in peritoneal dialysis patients: a comparison of two techniques. Perit Dial Int 2013; 33:655-61. [PMID: 24179108 PMCID: PMC3862095 DOI: 10.3747/pdi.2012.00298] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 01/30/2013] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Hand hygiene is essential for preventing peritoneal dialysis (PD)-related infections. The present study compared the effectiveness of two hygiene techniques in reducing the number of colony-forming units (CFUs) on the hands of patients undergoing PD. METHODS In this controlled clinical trial, 22 participants enrolled in the same PD program underwent a two-hand evaluation for microbiologic flora. Participants participated in two treatments: a) simple hand hygiene plus antiseptic hand hygiene, in which the patients washed their hands with water and glycerin soap for 1 minute and then rubbed and dried their hands with 70% ethyl alcohol gel; and b) antiseptic hand hygiene, in which the patients rubbed their hands with 70% ethyl alcohol gel until fully dry. To sample distal finger surfaces, we asked the participants to touch sheep blood agar plates directly. RESULTS The CFU count for both hands was significantly higher in the regular hygiene group than in the gel-only group [69.0 (16.0 - 101.0) CFU vs 9.0 (2.2 - 55.5) CFU, p < 0.010]. Growth of coagulase-negative Staphylococcus colonies was significantly higher in right-hand cultures from the regular hygiene group than in those from the gel-only group [69.5 (26.25 - 101.0) CFU vs 9.5 (1.0 - 41.7) CFU; p < 0.050]. CONCLUSIONS Among patients undergoing PD, using 70% ethyl alcohol gel to cleanse the hands may be more effective than following the regular hygiene recommendations in reducing bacterial populations.
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Affiliation(s)
- Ana Elizabeth Figueiredo
- School of Nursing, Physiotherapy and Nutrition,1 and Postgraduate Program in Medicine and Health Sciences, School of Medicine,2 Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
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Cho Y, Badve SV, Hawley CM, McDonald SP, Brown FG, Boudville N, Bannister KM, Clayton PA, Johnson DW. Association of biocompatible peritoneal dialysis solutions with peritonitis risk, treatment, and outcomes. Clin J Am Soc Nephrol 2013; 8:1556-63. [PMID: 23949232 DOI: 10.2215/cjn.12361212] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The effect of biocompatible peritoneal dialysis (PD) solutions on PD-related peritonitis is unclear. This study sought to evaluate the relationship between use of biocompatible solutions and the probability of occurrence or clinical outcomes of peritonitis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The study included all incident Australian patients receiving PD between January 1, 2007, and December 31, 2010, using Australia and New Zealand Dialysis and Transplant Registry data. All multicompartment PD solutions of neutral pH were categorized as biocompatible solutions. The independent predictors of peritonitis and the use of biocompatible solutions were determined by multivariable, multilevel mixed-effects Poisson and logistic regression analysis, respectively. Sensitivity analyses, including propensity score matching, were performed. RESULTS Use of biocompatible solutions gradually declined (from 7.5% in 2007 to 4.2% in 2010), with preferential use among smaller units and among younger patients without diabetes mellitus. Treatment with biocompatible solution was associated with significantly greater overall rate of peritonitis (0.67 versus 0.47 episode per patient-year; incidence rate ratio, 1.49; 95% confidence interval [CI], 1.19 to 1.89) and with shorter time to first peritonitis (hazard ratio [HR], 1.48; 95% CI, 1.17 to 1.87), a finding replicated in propensity score-matched cohorts (HR, 1.36; 95% CI, 1.09 to 1.71). CONCLUSIONS In an observational registry study, use of biocompatible PD solutions was associated with higher overall peritonitis rates and shorter time to first peritonitis. Further randomized studies adequately powered for a primary peritonitis outcome are warranted.
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Affiliation(s)
- Yeoungjee Cho
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
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Vychytil A. [Peritoneal dialysis from the beginnings up to today: which developments of the last decades were important?]. Wien Med Wochenschr 2013; 163:255-65. [PMID: 23591854 DOI: 10.1007/s10354-013-0191-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Accepted: 03/13/2013] [Indexed: 11/25/2022]
Abstract
During the past years new developments in peritoneal dialysis (PD) technique have resulted in continuous improvement of patient outcome. The importance of salt and fluid balance, residual renal function and peritoneal glucose load are of increasing interest, whereas small solute clearances have lost importance. In patients with high peritoneal transport rates automated PD (APD) is indicated. However, APD can also be chosen as initial PD treatment since recent studies show comparable or even better survival as compared to continuous ambulatory PD patients. Alternative PD solutions improve peritoneal ultrafiltration (icodextrin), reduce peritoneal glucose load (amino acid solution, icodextrin) and protect the peritoneal membrane (solutions with low concentration of glucose degradation products). Infection risk can be reduced when using antibiotic creams, but resistances should be considered. Ongoing studies will clarify if non-antibiotic agents, e.g. medihoney, are effective in preventing PD-associated infections. Due to these improvements PD and hemodialysis have become equivalent treatments.
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Affiliation(s)
- Andreas Vychytil
- Abteilung für Nephrologie und Dialyse, Klinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich.
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Schmitt CP, Nau B, Gemulla G, Bonzel KE, Hölttä T, Testa S, Fischbach M, John U, Kemper MJ, Sander A, Arbeiter K, Schaefer F. Effect of the dialysis fluid buffer on peritoneal membrane function in children. Clin J Am Soc Nephrol 2012; 8:108-15. [PMID: 23124784 DOI: 10.2215/cjn.00690112] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Double-chamber peritoneal dialysis fluids exert less toxicity by their neutral pH and reduced glucose degradation product content. The role of the buffer compound (lactate and bicarbonate) has not been defined in humans. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A multicenter randomized controlled trial in 37 children on automated peritoneal dialysis was performed. After a 2-month run-in period with conventional peritoneal dialysis fluids, patients were randomized to neutral-pH, low-glucose degradation product peritoneal dialysis fluids with 35 mM lactate or 34 mM bicarbonate content. Clinical and biochemical monitoring was performed monthly, and peritoneal equilibration tests and 24-hour clearance studies were performed at 0, 3, 6, and 10 months. RESULTS No statistically significant difference in capillary blood pH, serum bicarbonate, or oral buffer supplementation emerged during the study. At baseline, peritoneal solute equilibration and clearance rates were similar. During the study, 4-hour dialysis to plasma ratio of creatinine tended to increase, and 24-hour dialytic creatinine and phosphate clearance increased with lactate peritoneal dialysis fluid but not with bicarbonate peritoneal dialysis fluid. Daily net ultrafiltration, which was similar at baseline (lactate fluid=5.4±2.6 ml/g glucose exposure, bicarbonate fluid=4.9±1.9 ml/g glucose exposure), decreased to 4.6±1.0 ml/g glucose exposure in the lactate peritoneal dialysis fluid group, whereas it increased to 5.1±1.7 ml/g glucose exposure in the bicarbonate content peritoneal dialysis fluid group (P=0.006 for interaction). CONCLUSIONS When using biocompatible peritoneal dialysis fluids, equally good acidosis control is achieved with lactate and bicarbonate buffers. Improved long-term preservation of peritoneal membrane function may, however, be achieved with bicarbonate-based peritoneal dialysis fluids.
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Johnson DW, Cho Y, Brown FG. Trials (and tribulations) of biocompatible peritoneal dialysis fluids. Perit Dial Int 2012; 32:247-51. [PMID: 22641733 DOI: 10.3747/pdi.2012.00044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- David W Johnson
- Department of Renal Medicine, Princess Alexandra Hospital School of Medicine, University of Queensland, Brisbane, Australia.
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Buffer-dependent regulation of aquaporin-1 expression and function in human peritoneal mesothelial cells. Pediatr Nephrol 2012; 27:1165-77. [PMID: 22382466 DOI: 10.1007/s00467-012-2120-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 01/17/2012] [Accepted: 01/18/2012] [Indexed: 01/08/2023]
Abstract
BACKGROUND Biocompatible peritoneal dialysis fluids (PDF) are buffered with lactate and/or bicarbonate. We hypothesized that the reduced toxicity of the biocompatible solutions might unmask specific effects of the buffer type on mesothelial cell functions. METHODS Human peritoneal mesothelial cells (HPMC) were incubated with bicarbonate (B-)PDF or lactate-buffered (L-)PDF followed by messenger RNA (mRNA) and protein analysis. Gene silencing was achieved using small interfering RNA (siRNA), functional studies using Transwell culture systems, and monolayer wound-healing assays. RESULTS Incubation with B-PDF increased HPMC migration in the Transwell and monolayer wound-healing assay to 245 ± 99 and 137 ± 11% compared with L-PDF. Gene silencing showed this effect to be entirely dependent on the expression of aquaporin-1 (AQP-1) and independent of AQP-3. Exposure of HPMC to B-PDF increased AQP-1 mRNA and protein abundance to 209 ± 80 and 197 ± 60% of medium control; the effect was pH dependent. L-PDF reduced AQP-1 mRNA. Addition of bicarbonate to L-PDF increased AQP-1 abundance by threefold; mRNA half-life remained unchanged. Immunocytochemistry confirmed opposite changes of AQP-1 cell-membrane abundance with B-PDF and L-PDF. CONCLUSIONS Peritoneal mesothelial AQP-1 abundance and migration capacity is regulated by pH and buffer agents used in PD solutions. In vivo studies are required to delineate the impact with respect to long-term peritoneal membrane integrity and function.
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Müller-Krebs S, Kihm LP, Madhusudhan T, Isermann B, Reiser J, Zeier M, Schwenger V. Human RAGE antibody protects against AGE-mediated podocyte dysfunction. Nephrol Dial Transplant 2012; 27:3129-36. [DOI: 10.1093/ndt/gfs005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Johnson DW, Brown FG, Clarke M, Boudville N, Elias TJ, Foo MWY, Jones B, Kulkarni H, Langham R, Ranganathan D, Schollum J, Suranyi M, Tan SH, Voss D. Effects of biocompatible versus standard fluid on peritoneal dialysis outcomes. J Am Soc Nephrol 2012; 23:1097-107. [PMID: 22440906 DOI: 10.1681/asn.2011121201] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The clinical benefits of using "biocompatible" neutral pH solutions containing low levels of glucose degradation products for peritoneal dialysis compared with standard solutions are uncertain. In this multicenter, open-label, parallel-group, randomized controlled trial, we randomly assigned 185 incident adult peritoneal dialysis patients with residual renal function to use either biocompatible or conventional solution for 2 years. The primary outcome measure was slope of renal function decline. Secondary outcome measures comprised time to anuria, fluid volume status, peritonitis-free survival, technique survival, patient survival, and adverse events. We did not detect a statistically significant difference in the rate of decline of renal function between the two groups as measured by the slopes of GFR: -0.22 and -0.28 ml/min per 1.73 m(2) per month (P=0.17) in the first year in the biocompatible and conventional groups, respectively, and, -0.09 and -0.10 ml/min per 1.73 m(2) per month (P=0.9) in the second year. The biocompatible group exhibited significantly longer times to anuria (P=0.009) and to the first peritonitis episode (P=0.01). This group also had fewer patients develop peritonitis (30% versus 49%) and had lower rates of peritonitis (0.30 versus 0.49 episodes per year, P=0.01). In conclusion, this trial does not support a role for biocompatible fluid in slowing the rate of GFR decline, but it does suggest that biocompatible fluid may delay the onset of anuria and reduce the incidence of peritonitis compared with conventional fluid in peritoneal dialysis.
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Affiliation(s)
- David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD 4102, Australia.
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Jörres A. Novel Peritoneal Dialysis Solutions – What Are the Clinical Implications? Blood Purif 2012; 33:153-9. [DOI: 10.1159/000334151] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Morinaga H, Sugiyama H, Inoue T, Takiue K, Kikumoto Y, Kitagawa M, Akagi S, Nakao K, Maeshima Y, Miyazaki I, Asanuma M, Hiramatsu M, Makino H. Effluent free radicals are associated with residual renal function and predict technique failure in peritoneal dialysis patients. Perit Dial Int 2012; 32:453-61. [PMID: 22215657 DOI: 10.3747/pdi.2011.00032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Residual renal function (RRF) is associated with low oxidative stress in peritoneal dialysis (PD). In the present study, we investigated the relationship between the impact of oxidative stress on RRF and patient outcomes during PD. METHODS Levels of free radicals (FRs) in effluent from the overnight dwell in 45 outpatients were determined by electron spin resonance spectrometry. The FR levels, clinical parameters, and the level of 8-hydroxy-2'-deoxyguanosine were evaluated at study start. The effects of effluent FR level on technique and patient survival were analyzed in a prospective cohort followed for 24 months. RESULTS Levels of effluent FRs showed significant negative correlations with daily urine volume and residual renal Kt/V, and positive correlations with plasma β(2)-microglobulin and effluent 8-hydroxy-2'-deoxyguanosine. A highly significant difference in technique survival (p < 0.05), but not patient survival, was observed for patients grouped by effluent FR quartile. The effluent FR level was independently associated with technique failure after adjusting for patient age, history of cardiovascular disease, and presence of diabetes mellitus (p < 0.001). The level of effluent FRs was associated with death-censored technique failure in both univariate (p < 0.001) and multivariate (p < 0.01) hazard models. Compared with patients remaining on PD, those withdrawn from the modality had significantly higher levels of effluent FRs (p < 0.005). CONCLUSIONS Elevated effluent FRs are associated with RRF and technique failure in stable PD patients. These findings highlight the importance of oxidative stress as an unfavorable prognostic factor in PD and emphasize that steps should be taken to minimize oxidative stress in these patients.
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Affiliation(s)
- Hiroshi Morinaga
- Department of Medicine and Clinical Science, Center for Chronic Kidney Disease and Peritoneal Dialysis, Okayama University Graduate School of Medicine, Okayama, Japan
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Lai KN, Lam MF, Leung JCK, Chan LY, Lam CWK, Chan IHS, Chan HW, Li CS, Wong SSH, Ho YW, Cheuk A, Tong MKL, Tang SCW. A study of the clinical and biochemical profile of peritoneal dialysis fluid low in glucose degradation products. Perit Dial Int 2011; 32:280-91. [PMID: 22045098 DOI: 10.3747/pdi.2010.00176] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Although peritoneal dialysis (PD) is a widely accepted form of renal replacement therapy, concerns remain regarding the bioincompatible nature of standard PD fluid (PDF). Short-term studies of new biocompatible PDFs low in glucose degradation products (GDPs) reveal divergent results with respect to peritoneal integrity. METHODS We studied 125 patients on maintenance PD who were assigned, by simple randomization, to receive either conventional or low-GDP PDF at PD initiation. Parameters of dialysis adequacy and peritoneal transport of small solutes were determined at initiation and after a period of maintenance PD at the time when serum and overnight effluent dialysate were simultaneously collected and assayed for various cytokines, chemokines, adipokines, and cardiac biomarkers. All patients were further followed prospectively for an average of 15 months from the day of serum and effluent collection to determine patient survival and cardiovascular events. RESULTS Patients treated with conventional or low-GDP PDF were matched for sex, age, duration of dialysis, dialysis adequacy, and incidence of cardiovascular disease or diabetes. After an average of 2.3 years of PD treatment, the weekly total and peritoneal creatinine clearance, and the total and peritoneal Kt/V were comparable in the groups. However, urine output was higher in patients using low-GDP PDF despite there having been no difference between the groups at PD initiation. Patients using low-GDP PDF also experienced a slower rate of decline of residual glomerular filtration and urine output than did patients on conventional PDF. Compared with serum concentrations, effluent concentrations of tumor necrosis factor α, hepatocyte growth factor, macrophage migration inhibitory factor, interleukins 8 and 6, C-reactive protein, and leptin were found to be higher in both groups of patients after long-term PD, suggesting that the peritoneal cavity was the major source of those mediators. Compared with patients on low-GDP PDF, patients on conventional fluid showed elevated leptin and reduced adiponectin levels in serum and effluent. The effluent concentration of interleukin 8 was significantly lower in patients using low-GDP PDF. The survival rate and incidence of cardiovascular complications did not differ between these groups after maintenance PD for an average of 3.6 years. CONCLUSIONS It appears that low-GDP PDF results in an improvement of local peritoneal homeostasis through a reduction of chronic inflammatory status in the peritoneum.
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Affiliation(s)
- Kar Neng Lai
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, PR China.
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Ryckelynck JP, Abbadie O, Castrale C, Lavainne F, Fakhouri F, Lobbedez T. [Why and how to promote peritoneal dialysis?]. Presse Med 2011; 40:1053-8. [PMID: 21924862 DOI: 10.1016/j.lpm.2011.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 06/10/2011] [Indexed: 11/26/2022] Open
Abstract
The prevalence of peritoneal dialysis in France remains one of the lowest in Europe in spite of official recommendations in 2008. Progress in peritoneal catheter placement and a good knowledge of the management of catheter complications are essential. A more frequent use of biocompatible solutions should achieve a better preservation of the peritoneal membrane. Such physiological peritoneal fluids seem to decrease morbidity and mortality. Best peritoneal dialysis indications are mainly young patients waiting for a kidney transplantation, old patients without malnutrition and patients with cardiac insufficiency. Objective and complete information dedicated to both peritoneal dialysis and hemodialysis is necessary, even for patients seen in emergency or unplanned or late referral patients. A pre-end-stage renal disease education program has to be mandatory. Non-medical obstacles, mainly financial, are still common so that economic incitations are necessary for the development of peritoneal dialysis. A university formation of nephrologists is now available.
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Abstract
Despite substantial advances in peritoneal dialysis (PD) as a renal replacement modality, PD-related infection remains an important cause of morbidity, technique failure, and mortality. This review describes the microbiology and outcomes of PD peritonitis and catheter infection, followed by a discussion of several strategies that may reduce the risk of PD-related infections. Strategies that are reviewed include use of antibiotics at the time of PD catheter insertion, selection of PD catheter design and insertion technique, patient training, PD connectology, exit site prophylaxis, periprocedural prophylaxis, fungal prophylaxis, and choice of PD solutions.
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Schmitt CP, Bakkaloglu SA, Klaus G, Schröder C, Fischbach M. Solutions for peritoneal dialysis in children: recommendations by the European Pediatric Dialysis Working Group. Pediatr Nephrol 2011; 26:1137-47. [PMID: 21448787 DOI: 10.1007/s00467-011-1863-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 02/11/2011] [Accepted: 02/14/2011] [Indexed: 10/18/2022]
Abstract
The purpose of this article is to provide recommendations on the choice of peritoneal dialysis (PD) fluids in children by the European Pediatric Dialysis Working Group. The literature on experimental and clinical studies with PD solutions in children and adults was analyzed together with consensus discussions within the group. A grading was performed based on the international KDIGO nomenclature and methods. The lowest glucose concentration possible should be used. Icodextrin may be applied once daily during the long dwell, in particular in children with insufficient ultrafiltration. Infants on PD are at risk of ultrafiltration-associated sodium depletion, while anuric adolescents may have water and salt overload. Hence, the sodium chloride balance needs to be closely monitored. In growing children, the calcium balance should be positive and dialysate calcium adapted according to individual needs. Limited clinical experience with amino acid-based PD fluids in children suggests good tolerability. The anabolic effect, however, is small; adequate enteral nutrition is preferred. CPD fluids with reduced glucose degradation products (GDP) content reduce local and systemic toxicity and should be preferred whenever possible. Correction of metabolic acidosis is superior with pH neutral bicarbonate-based fluids compared with single-chamber, acidic, lactate-based solutions. Prospective comparisons of low GDP solutions with different buffer compositions are still few, and firm recommendations cannot yet be given, except when hepatic lactate metabolism is severely compromised.
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Affiliation(s)
- Claus Peter Schmitt
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, INF 430, 69120 Heidelberg, Germany.
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Schmitt CP, Zaloszyc A, Schaefer B, Fischbach M. Peritoneal dialysis tailored to pediatric needs. Int J Nephrol 2011; 2011:940267. [PMID: 21761001 PMCID: PMC3132841 DOI: 10.4061/2011/940267] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 03/29/2011] [Indexed: 02/02/2023] Open
Abstract
Consideration of specific pediatric aspects is essential to achieve adequate peritoneal dialysis (PD) treatment in children. These are first of all the rapid growth, in particular during infancy and puberty, which must be accompanied by a positive calcium balance, and the age dependent changes in body composition. The high total body water content and the high ultrafiltration rates required in anuric infants for adequate nutrition predispose to overshooting convective sodium losses and severe hypotension. Tissue fragility and rapid increases in intraabdominal fat mass predispose to hernia and dialysate leaks. Peritoneal equilibration tests should repeatedly been performed to optimize individual dwell time. Intraperitoneal pressure measurements give an objective measure of intraperitoneal filling, which allow for an optimized dwell volume, that is, increased dialysis efficiency without increasing the risk of hernias, leaks, and retrofiltration. We present the concept of adapted PD, that is, the combination of short dwells with low fill volume to promote ultrafiltration and long dwells with a high fill volume to improve purification within one PD session. The use of PD solutions with low glucose degradation product content is recommended in children, but unfortunately still not feasible in many countries.
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Affiliation(s)
- C P Schmitt
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, INF 430, 69120 Heidelberg, Germany
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Theodoridis M, Tziakas D, Passadakis P, Kantartzi K, Roumeliotis A, Thodis E, Vargemezis V. The effect of bicarbonate peritoneal dialysis solutions on cardiac structural and functional alterations. Nephrol Dial Transplant 2011; 26:4061-7. [PMID: 21543656 DOI: 10.1093/ndt/gfr206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The systemic effects of absorbed glucose degradation products (GDPs) contained within the conventional peritoneal dialysis solutions (cPDS) are largely unknown, while they appear to affect also cardiovascular function. The aim of the present study was to evaluate if the new bicarbonate-based less bioincompatible new peritoneal dialysis solutions ameliorate cardiac structural and functional status as well as the peritoneal net ultrafiltration (UF) and residual renal function. Patients and methods. This is a single centre, prospective cohort study of 12 stable continues ambulatory peritoneal dialysis patients (four women, eight men) mean aged 71.3 ± of 6.01 years and mean peritoneal dialysis (PD) duration 31.9 ± 21.33 months, treated with the usual cPDS (Medital Bieffe®, with increased GDPs, low pH and lactate as a buffer system). The patients changed for a 6-month period to the newer biocompatible PD solutions (BicaVera, Fresenius® low GDPs, normal pH, bicarbonate as a buffer) and at the end of this time, they returned to their previous schema of conventional solutions, for another 6 months. During the study period, the left ventricle ejection fraction (EF), left ventricle end systolic and diastolic diameter (LVESD, LVEDD), left ventricle mass index (LVMI), glyoxal serum and peritoneal concentrations, net UF and 24 h urine volume were repeatedly estimated: at the beginning of the study (T0), after 6 months with the biocompatible solutions (T6) and at the end of study (T12), after the 6-month period using again the cPDS. The UF volume and glyoxal concentrations were estimated at end of a 4 h dwell of an exchange with a PD solution of 2.27 % glucose. RESULTS There was a statistically significant difference between the mean levels of EF, LVESD, LVEDD, LVMI, UF and glyoxal serum and peritoneal concentrations at the beginning (T0) and in the middle of the study (T6) (for serum glyoxal P = 0.005, for peritoneal glyoxal P = 0.0004, for EF P = 0.0004, for LVESD P = 0.023, for LVEDD P = 0.002, for LVMI P = 0.0005 and for UF P = 0.005) as well as between the mean values in the middle (T6) and at the end of the evaluation period (T12) (for serum glyoxal P = 0.043, for peritoneal glyoxal P = 0.006, for EF P = 0.00009, for LVESD P = 0.012, for LVEDD P = 0.00014, for LVMI P = 0.00013 and for UF P = 0.048). On the other hand, no statistically significant difference was revealed between the T0 and T12 mean values of glyoxal (serum and peritoneal), EF, LVESD, LVEDD, LVMI and UF. During the study period, there was no statistically significant difference in daily urine volume and glomerular filtration rate. CONCLUSIONS The use of bicarbonate-based PDS induced a statistically significant improvement of left ventricle structure (LVESD, LVEDD and LVMI) and functional (EF) indicators. These beneficial effects on left ventricle in combination with the improvement of net UF may designate a protective role of the newer bicarbonate peritoneal solutions on cardiovascular function morbidity and mortality risk of PD patients.
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Affiliation(s)
- Marios Theodoridis
- Department of Nephrology, University Hospital of Alexandroupolis, Alexandroupolis, Greece.
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Perl J, Nessim SJ, Bargman JM. The biocompatibility of neutral pH, low-GDP peritoneal dialysis solutions: benefit at bench, bedside, or both? Kidney Int 2011; 79:814-24. [DOI: 10.1038/ki.2010.515] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Skin autofluorescence as a measure of advanced glycation endproduct deposition: a novel risk marker in chronic kidney disease. Curr Opin Nephrol Hypertens 2011; 19:527-33. [PMID: 20844429 DOI: 10.1097/mnh.0b013e32833e9259] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Skin autofluorescence (SAF) is a new method to noninvasively assess accumulation of advanced glycation endproducts (AGEs) in a tissue with low turnover. Recent progress in the clinical application of SAF as a risk marker for diabetic nephropathy as well as cardiovascular disease in nondiabetic end-stage kidney disease, less advanced chronic kidney disease, and renal transplant recipients is reviewed. RECENT FINDINGS Experimental studies highlight the fundamental role of the interaction of AGEs with the receptor for AGEs (RAGEs), also called the AGE-RAGE axis, in the pathogenesis of vascular and chronic kidney disease. SAF predicts (cardiovascular) mortality in renal failure and also chronic renal transplant dysfunction. Long-term follow-up results from the Diabetes Control and Complications Trial and UK Prospective Diabetes Study suggest that AGE accumulation is a key carrier of metabolic memory and oxidative stress. Short-term intervention studies in diabetic nephropathy with thiamine, benfotiamine and angiotensin-receptor blockers aimed at reducing AGE formation have reported mixed results. SUMMARY SAF is a noninvasive marker of AGE accumulation in a tissue with low turnover, and thereby of metabolic memory and oxidative stress. SAF independently predicts cardiovascular and renal risk in diabetes, as well as in chronic kidney disease. Further long-term studies are required to assess the potential benefits of interventions to reduce AGE accumulation.
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Müller-Krebs S, Kihm LP, Zeier B, Gross ML, Wieslander A, Haug U, Zeier M, Schwenger V. Glucose degradation products result in cardiovascular toxicity in a rat model of renal failure. Perit Dial Int 2011; 30:35-40. [PMID: 20056977 DOI: 10.3747/pdi.2009.00031] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND It has been shown that glucose degradation products (GDP) generated during heat sterilization of peritoneal dialysis (PD) fluids impair the peritoneal membrane locally, then enter the systemic circulation and cause damage to the remnant kidney. Here we examined in subtotally nephrectomized (SNX) rats whether GDP also affect the cardiovascular system. MATERIALS AND METHODS Standard 5/6 nephrectomy was carried out in Sprague-Dawley rats; other rats were sham operated and left untreated for 3 weeks. Through an osmotic mini-pump, SNX+GDP group received GDP intravenously for 4 weeks; the SNX and the sham-operated groups remained without GDP. The experiment was terminated for all groups 7 weeks postoperatively. We analyzed cardiovascular damage by serum analyses and immunohistochemical investigation. RESULTS In SNX+GDP animals, expression of the advanced glycation end product (AGE) marker carboxymethyllysine and receptor of AGE (RAGE) were significantly higher in the myocardium and the aorta compared to the SNX rats. We also found significantly higher levels of apoptosis measured by caspase 3 staining in the cardiovascular system in the SNX+GDP group. Moreover, we observed a more pronounced expression of oxidative stress in the SNX+GDP rats compared to the SNX rats. In serum analyses, advanced oxidation protein products and reactive oxygen species were increased, as was immunohistochemical endothelial nitric oxide synthase. CONCLUSIONS In addition to local toxic effects, GDP cause systemic toxicity. Here we showed that, in SNX rats, administration of GDP increased cardiovascular damage. In particular, we found increased levels of AGE, RAGE, oxidative stress, and apoptosis. Whether these findings are of clinical relevance has to be further investigated.
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JOSE MATTHEWD, JOHNSON DAVIDW, MUDGE DAVIDW, TRANAEUS ANDERS, VOSS DAVID, WALKER ROWAN, BANNISTER KYMM. Peritoneal dialysis practice in Australia and New Zealand: A call to action. Nephrology (Carlton) 2010; 16:19-29. [DOI: 10.1111/j.1440-1797.2010.01390.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Johnson DW, Clarke M, Wilson V, Woods F, Brown FG. Rationale and design of the balANZ trial: a randomised controlled trial of low GDP, neutral pH versus standard peritoneal dialysis solution for the preservation of residual renal function. BMC Nephrol 2010; 11:25. [PMID: 20843375 PMCID: PMC2954914 DOI: 10.1186/1471-2369-11-25] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 09/16/2010] [Indexed: 11/18/2022] Open
Abstract
Background The main hypothesis of this study is that neutral pH, low glucose degradation product (GDP) peritoneal dialysis (PD) fluid better preserves residual renal function in PD patients over time compared with conventional dialysate. Methods/Design Inclusion criteria are adult PD patients (CAPD or APD) aged 18-81 years whose first dialysis was within 90 days prior to or following enrolment and who have a residual GFR ≥ 5 ml/min/1.73 m2, a urine output ≥ 400 ml/day and an ability to understand the nature and requirements of this trial. Pregnant or lactating patients or individuals with an active infection at the time of enrolment, a contra-indication to PD or participation in any other clinical trial where an intervention is designed to moderate rate of change of residual renal function are excluded. Patients will be randomized 1:1 to receive either neutral pH, low GDP dialysis solution (Balance®) or conventional dialysis solution (Stay.safe®) for a period of 2 years. During this 2 year study period, urinary urea and clearance measurements will be performed at 0, 3, 6, 9, 12, 18 and 24 months. The primary outcome measure will be the slope of residual renal function decline, adjusted for centre and presence of diabetic nephropathy. Secondary outcome measures will include time from initiation of peritoneal dialysis to anuria, peritoneal small solute clearance, peritoneal transport status, peritoneal ultrafiltration, technique survival, patient survival, peritonitis rates and adverse events. A total of 185 patients has been recruited into the trial. Discussion This investigator-initiated study has been designed to provide evidence to help nephrologists determine the optimal dialysis solution for preserving residual renal function in PD patients. Trial Registration Australian New Zealand Clinical Trials Registry Number: ACTRN12606000044527
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Affiliation(s)
- David W Johnson
- Department of Renal Medicine, Princess Alexandra Hospital, Brisbane, Australia.
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Kendrick J, Teitelbaum I. Strategies for improving long-term survival in peritoneal dialysis patients. Clin J Am Soc Nephrol 2010; 5:1123-31. [PMID: 20430945 DOI: 10.2215/cjn.04300709] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The incidence and prevalence of ESRD in the United States continues to increase. Currently there are over 26,000 patients maintained on peritoneal dialysis. Mortality rates have fallen over the past several years, but long-term survival remains poor, with only 11% of peritoneal dialysis patients surviving past 10 years. Cardiovascular disease accounts for most deaths, and dialysis patients have many traditional and nontraditional cardiovascular risk factors. Lowering of these risk factors has not resulted in reduced cardiovascular morbidity and mortality in dialysis patients. Maneuvers to improve long-term peritoneal dialysis patient survival must therefore focus on modifiable risk factors including residual renal function, peritoneal membrane integrity, rate of infections, and peritoneal dialysis center size. This article reviews strategies for preserving residual renal function and peritoneal membrane integrity as well as strategies for reducing the rate of infections to enhance long-term survival in peritoneal dialysis patients.
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Affiliation(s)
- Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Health Sciences Center, Aurora, CO, USA
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Infusion fluids contain harmful glucose degradation products. Intensive Care Med 2010; 36:1213-20. [PMID: 20397009 PMCID: PMC2882046 DOI: 10.1007/s00134-010-1873-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 03/07/2010] [Indexed: 01/04/2023]
Abstract
Purpose Glucose degradation products (GDPs) are precursors of advanced glycation end products (AGEs) that cause cellular damage and inflammation. We examined the content of GDPs in commercially available glucose-containing infusion fluids and investigated whether GDPs are found in patients’ blood. Methods The content of GDPs was examined in infusion fluids by high-performance liquid chromatography (HPLC) analysis. To investigate whether GDPs also are found in patients, we included 11 patients who received glucose fluids (standard group) during and after their surgery and 11 control patients receiving buffered saline (control group). Blood samples were analyzed for GDP content and carboxymethyllysine (CML), as a measure of AGE formation. The influence of heat-sterilized fluids on cell viability and cell function upon infection was investigated. Results All investigated fluids contained high concentrations of GDPs, such as 3-deoxyglucosone (3-DG). Serum concentration of 3-DG increased rapidly by a factor of eight in patients receiving standard therapy. Serum CML levels increased significantly and showed linear correlation with the amount of infused 3-DG. There was no increase in serum 3-DG or CML concentrations in the control group. The concentration of GDPs in most of the tested fluids damaged neutrophils, reducing their cytokine secretion, and inhibited microbial killing. Conclusions These findings indicate that normal standard fluid therapy involves unwanted infusion of GDPs. Reduction of the content of GDPs in commonly used infusion fluids may improve cell function, and possibly also organ function, in intensive-care patients. Electronic supplementary material The online version of this article (doi:10.1007/s00134-010-1873-x) contains supplementary material, which is available to authorized users.
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Bargman JM. Slouching towards Bethlehem: the beast of biocompatibility. Nephrol Dial Transplant 2010; 25:2050-1. [PMID: 20395255 DOI: 10.1093/ndt/gfq213] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joanne M Bargman
- Home Peritoneal Dialysis Unit, University Health Network, University of Toronto, Toronto, Canada.
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Haag-Weber M, Krämer R, Haake R, Islam MS, Prischl F, Haug U, Nabut JL, Deppisch R. Low-GDP fluid (Gambrosol trio) attenuates decline of residual renal function in PD patients: a prospective randomized study. Nephrol Dial Transplant 2010; 25:2288-96. [PMID: 20197284 DOI: 10.1093/ndt/gfq087] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Residual renal function (RRF) impacts outcome of peritoneal dialysis (PD) patients. Some PD fluids contain glucose degradation products (GDPs) which have been shown to affect cell systems and tissues. They may also act as precursors of advanced glycosylation endproducts (AGEs) both locally and systemically, potentially inflicting damage to the kidney as the major organ for AGE elimination. We conducted a clinical study in PD patients to see if the content of GDP in the PD fluid has any influence on the decline of the residual renal function. METHODS In a multicentre approach, 80 patients (GFF > or = 3 mL/min/1.732 or creatinine clearance > or =3 mL/min/1.73 m(2)) were randomized to treatment with a PD fluid containing low levels of GDP or standard PD fluid for 18 months. RRF was assessed every 4-6 weeks. Fluid balance, mesothelial cell mass marker CA125, peritoneal membrane characteristics, C-reactive protein (CRP), total protein, albumin, electrolytes and phosphate were measured repeatedly. RESULTS Data from 69 patients revealed a significant difference in monthly RRF change: -1.5% (95% CI = -3.07% to +0.03%) with low GDP (43 patients) vs -4.3% (95% CI = -6.8% to -2.06%) with standard fluids (26 patients) (P = 0.0437), independent of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker medication. Twenty-four-hour urine volume declined more slowly with low-GDP fluid compared to standard fluids (12 vs 38 mL/month, P = 0.0241), and monthly change of phosphate level was smaller (+0.013 vs +0.061 mg/dL, P = 0.0381). CONCLUSIONS Our prospective study demonstrates for the first time a significant benefit concerning preservation of RRF and urine volume of using a PD fluid with low GDP levels. These findings suggest that GDPs might affect patient outcome related to RRF.
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Chaudhary K, Khanna R. Biocompatible Peritoneal Dialysis Solutions: Do We Have One?: Table 1. Clin J Am Soc Nephrol 2010; 5:723-32. [DOI: 10.2215/cjn.05720809] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Vonesh E. On Small Solute Clearance and Patient Outcomes: Evidential Practice or Observational Trepidation? Perit Dial Int 2009. [DOI: 10.1177/089686080902900606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Recent guidelines on peritoneal dialysis adequacy set a minimum target for small solute clearance at Kt/V urea 1.70. While evidence from both observational studies and randomized controlled trials (RCTs) supports such a minimum target, there continues to be debate over what role small solute clearance plays in determining patient outcome. Current ANZDATA Registry results from Australia and New Zealand add fuel to this debate by demonstrating a significant nonlinear U-shaped relationship between peritoneal small solute clearance and patient survival. The ANZDATA results indicate that patients with too low or too high peritoneal Kt/V urea may be at significant risk of death compared to those with a peritoneal Kt/V urea between 1.70 and 2.00. As these results are somewhat at odds with results from published RCTs, we will examine the level of evidence from the observational setting that is the ANZDATA Registry and contrast it against the level of evidence from RCTs, particularly the ADEMEX trial. New results from the ADEMEX study are presented as a possible explanation for the paradoxical U-shaped results seen in the ANZDATA study.
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Peritoneal Small Solute Clearance is Nonlinearly Related to Patient Survival in the Australian and New Zealand Peritoneal Dialysis Patient Populations. Perit Dial Int 2009. [DOI: 10.1177/089686080902900609] [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
Background The contribution of peritoneal small solute clearance per se to peritoneal dialysis (PD) patient outcomes remains uncertain. The aim of the present study was to determine whether baseline peritoneal small solute clearance predicted subsequent survival in Australian and New Zealand PD patients. Methods The study included all adult patients in Australia and New Zealand that commenced PD between 1 April 2002 and 31 December 2005 and had a peritoneal Kt/V (pKt/V) measurement performed within 6 months of PD commencement. Time to death and death-censored technique failure were examined by Kaplan–Meier analyses and both univariate and multivariate Cox proportional hazards models. Results pKt/V measurements were available in 2434 (63%) of the 3841 individuals that began PD treatment in Australia and New Zealand during the study period. These patients were divided into 4 groups according to their baseline pKt/V values: <1.45 ( n = 599), 1.45 – 1.69 ( n = 550), 1.70 – 2.00 ( n = 607), and >2.00 ( n = 678). Compared with the reference group (pKt/V 1.70 – 2.00), patient mortality was significantly increased in individuals with pKt/V <1.45 [adjusted hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.24 – 2.84; p = 0.003] and tended to be increased in those with pKt/V 1.45 – 1.69 (adjusted HR 1.46, 95% CI 0.96 – 2.21; p = 0.074). Importantly, higher pKt/V values (>2.00) also tended to be associated with higher mortality (adjusted HR 1.42, 95% CI 0.96 – 2.11; p = 0.079). The other independent predictors of death were lower residual renal function (RRF), older age, peripheral vascular disease, diabetes mellitus, late referral, higher peritoneal permeability, and untreated hypertension. No interaction was observed between pKt/V, RRF, and survival. Death-censored technique failure was demonstrated to be significantly worse in the pKt/V 1.45 – 1.69 group (adjusted HR 1.36, 95% CI 1.03 – 1.79; p = 0.028), older individuals, and individuals with Asian racial origin. Conclusions Initial peritoneal Kt/V significantly and independently influences patient survival in Australian and New Zealand PD patients. Overall survival appears to be optimal in the pKt/V range 1.70 – 2.00, with poorer outcomes observed above and below these values. In particular, survival is significantly worse when the achieved pKt/V is <1.45. In addition, RRF is an important independent predictor of patient survival in the Australian and New Zealand incident PD patient populations. The results of this study should therefore draw attention to the possible danger of not delivering adequate PD dose to patients with considerable RRF.
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Han SH, Ahn SV, Yun JY, Tranaeus A, Han DS. Mortality and technique failure in peritoneal dialysis patients using advanced peritoneal dialysis solutions. Am J Kidney Dis 2009; 54:711-20. [PMID: 19619922 DOI: 10.1053/j.ajkd.2009.05.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2009] [Accepted: 05/20/2009] [Indexed: 11/11/2022]
Abstract
BACKGROUND Despite the theoretical benefits of biocompatible physiological-pH bicarbonate/lactate-buffered (B/L) peritoneal dialysis solution, there is only limited evidence supporting a superior clinical outcome associated with its use. STUDY DESIGN Observational study. SETTINGS & PARTICIPANTS 2,163 patients starting peritoneal dialysis therapy between July 2003 and December 2006 from 54 centers in Korea were enrolled. PREDICTORS B/L solution and icodextrin use. OUTCOMES All-cause mortality and technique failure. MEASUREMENTS Patient outcomes were compared between patients prescribed B/L and conventional solutions by using propensity score and intention-to-treat analyses. RESULTS 542 patients initiated peritoneal dialysis therapy with B/L solution, and 1,621, with conventional solution. Fifteen patients prescribed B/L solution switched to conventional solution, and 386 of those initially using conventional solution switched to B/L solution during follow-up. Propensity score matching yielded 542 matched pairs of patients. In the matched cohort, there were no significant differences in age, diabetes, cardiovascular comorbidity, socioeconomic status, icodextrin use, or center experience between the 2 groups. All-cause deaths occurred in 52 (9.6%) patients in the B/L-solution group compared with 102 (18.9%) in the conventional-solution group (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.50 to 0.98; P = 0.04). In addition, icodextrin use was significantly associated with a reduced risk of death (HR, 0.40; 95% CI, 0.28 to 0.58; P < 0.001). Thirty-three (6.1%) and 48 (8.9%) technique failures occurred in the B/L- and conventional-solution groups, respectively (HR, 0.91; 95% CI, 0.58 to 1.43; P = 0.7). The survival benefit of B/L solution persisted in the unmatched cohort (HR, 0.69; 95% CI, 0.52 to 0.93; P = 0.02). LIMITATIONS Retrospective analysis, lack of laboratory data, and unknown indications for use of B/L solution. CONCLUSION Use of a biocompatible B/L peritoneal dialysis solution with physiological pH is associated with improved survival compared with conventional solution. Large randomized clinical trials are warranted to confirm this finding.
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Affiliation(s)
- Seung Hyeok Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Ryckelynck JP, Lobbedez T, Ficheux M, Chatelet V, Thuillier-Lecouf A, Henri P, Hurault de Ligny B. Evaluation médico-économique des nouvelles solutions en dialyse péritonéale. Nephrol Ther 2009; 5 Suppl 4:S286-9. [DOI: 10.1016/s1769-7255(09)74560-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Noordzij MJ, Lefrandt JD, Smit AJ. Advanced glycation end products in renal failure: an overview. J Ren Care 2009; 34:207-12. [PMID: 19090900 DOI: 10.1111/j.1755-6686.2008.00038.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The article aims to present an overview of the existing knowledge on advanced glycation end products (AGE). They are moieties that bind to proteins, but also lipids and nuclear acids. AGE are formed during glycation and oxidative stress. Accumulation of AGE occurs especially in diabetes and chronic renal failure and plays a major pathogenetic role. The deleterious effects of AGE result from cross-linking of proteins and activation of the receptor for advanced glycation end products. AGE accumulation can be noninvasively assessed by the skin autofluorescence reader. In diabetics, the skin autofluorescence predicts cardiac mortality and the occurrence of macro- and microvascular complications. In patients on haemodialysis, skin autofluorescence is highly elevated and predicts mortality. After renal transplantation AGE accumulation is lower than during haemodialysis, but still remains elevated and is a strong risk factor for chronic renal transplant dysfunction. Some of the potential methods to intervene with AGE accumulation are discussed in this article.
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Affiliation(s)
- M J Noordzij
- Department of Internal Medicine, Division of Vascular Medicine, University Medical Center Groningen, University of Groningen, The Netherlands.
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Erixon M, Wieslander A, Lindén T, Carlsson O, Jönsson JÅ, Simonsen O, Kjellstrand P. 3,4-Dideoxyglucosone-3-Ene in Peritoneal Dialysis Fluids Infused into the Peritoneal Cavity Cannot be Found in Plasma. Perit Dial Int 2009. [DOI: 10.1177/089686080902902s04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Glucose degradation products (GDPs) are important for the outcome of peritoneal dialysis (PD) treatment. The most cytotoxic GDP found in conventionally manufactured fluids, 3,4-dideoxyglucosone-3-ene (3,4-DGE), may in addition be recruited from 3-deoxyglucosone (3-DG). What happens with the GDPs in the fluid infused into patients during PD is not known. We investigated whether 3,4-DGE and 3-DG in PD fluid can be found in plasma during treatment. Design Patients on PD were dialyzed with a conventional PD fluid containing 43 μmol/L 3,4-DGE and 281 μmol/L 3-DG. Parallel experiments were performed in rats and in vitro with human plasma. The rats were dialyzed with a PD fluid containing 100 μmol/L 3,4-DGE and 200 μmol/L 3-DG. Results The 3,4-DGE concentration in the peritoneum declined at a much higher rate during the dwell than did the 3-DG concentration. However, 3,4-DGE was not detected in the plasma of patients or of rats during dialysis. The 3-DG concentration in plasma peaked shortly after infusion of fluid into the peritoneal cavity. The 3,4-DGE concentration during experimental incubation in plasma declined rapidly; the 3-DG concentration declined only 10% as rapidly (or less). Conclusion During dialysis, 3,4-DGE could not be detected in plasma of either PD patients or rats, presumably because of its high reactivity. On the other hand, 3-DG may pass through the membrane and be detected in the blood.
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Affiliation(s)
- Martin Erixon
- Gambro AB, Lund, Sweden
- Analytical Chemistry, University of Lund
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