Perioperative Management and Surgical Outcomes of Colorectal Cancer Patients Undergoing Peritoneal Dialysis for End-Stage Kidney Disease

Introduction: Despite the fact that the number of peritoneal dialysis (PD) patients is increasing, there is little evidence on the surgical outcomes of PD patients who have colorectal cancer surgery, and there is no consensus on the safety and practicality of continuing PD.

Methods: We retrospectively evaluated the short- and long-term results, as well as the feasibility of continuing PD, in eight patients with PD who had colorectal cancer surgery at our institution between January 2010 and January 2021.

Results: The scheduled open-fashioned resection was performed in one patient, whereas the other seven surgeries were all conducted laparoscopically, with no intraoperative conversion to laparotomy necessary. Except for one patient with a history of recurring PD-related peritonitis, the PD catheter was kept in seven of the eight cases. Five of the seven patients continuing PD underwent temporary postoperative hemodialysis. At a median of 24.5 months of postoperative monitoring, no infectious complications were observed, six cases continued PD, and no recurrence of colorectal cancer was observed in all cases.

Conclusions: Routine curative-intent colorectal cancer surgery with the preservation of the PD catheter is possible and safe in individuals receiving PD. This patient population's short- and long-term oncological results are comparable to general surgical outcomes of those without chronic kidney disease. PD can be maintained for a long period of time following major colorectal cancer surgery.

How to Improve Survival in Geriatric Peritoneal Dialysis Patients

♦ Background

Recently, more elderly patients who are independent or able to live at home with the support of family are opting for continuous ambulatory peritoneal dialysis (CAPD). At the end of 2005, the annual statistical survey conducted by the Japanese Society for Dialysis Therapy indicated that the mean age of patients at initiation of dialysis treatment is 66.2 years. Only 3.6% of the overall end-stage renal disease population were treated with CAPD, and this small number of elderly patients was treated with CAPD despite the many merits of peritoneal dialysis (PD) for the elderly. In the present study, we reviewed our experience with patients 65 years of age and older at the start of PD and the results from two multicenter studies on PD treatment in elderly patients in Japan.

♦ Patients and Methods

Study 1: Of 313 PD patients at Okayama Saiseikai General Hospital between January 1991 and June 2006, 166 patients 65 years of age and older were studied. The characteristics of these elderly PD patients were reviewed to determine which elderly patients can continue PD for more than 5 years, and what the causes of death and the effects of icodextrin were in elderly PD patients. Study 2: A multicenter study of 421 patients introduced to PD from April 2000 to December 2004 in Japan was carried out by the Japanese Society for Elderly Patients on Peritoneal Dialysis to retrospectively analyze patient survival and technique survival and to find factors that have the potential to influence prognosis in these patients. Study 3: A review of the PD management and nursing-care insurance system (long-term care insurance) targeted patients 65 years of age and older who were initiated onto PD from January 2000 to June 2002 at 82 centers in Japan. The review found 765 patients under the age of 65 years (62.6%), and 458 patients 65 years of age and over (37.4%). Data on 409 elderly PD patients from 73 centers were analyzed.

♦ Results

Study 1: In 166 elderly patients, 27 (16.3%; 18 women, 9 men) continued PD for more than 5 years at our hospital. The original disease was chronic glomerulonephritis in 21 patients, diabetic nephropathy in 2 patients, nephrosclerosis in 2 patients, and polycystic kidney disease in 2 patients. The causes of death in the elderly PD patients at our hospital were heart failure (20.3%), cerebrovascular disease (17.7%), myocardial infarction (15.2%), debilitation (12.7%), peritonitis (7.6%), and pneumonia (3.8%). We observed significant differences in ultrafiltration, body weight, sodium, chloride, red blood cells, and hematocrit after using icodextrin in 14 elderly PD patients. Also, use of icodextrin in the daytime helps the family supporting an elderly member on PD by reducing the number of exchanges. Study 2: The average age of 421 patients in 37 hospitals throughout Japan was 76.4 years. Women accounted for 41% of all patients. The average modified (exclusive of factors of aging) Charlson comorbidity index (CCI) was 3.7. The modified CCI was an important factor not only in patient survival but also in technique survival. Patient survival was significantly different for the three modified CCI groups (CCI < 3, 3 ≤ CCI < 5, 5 ≤ CCI). Factors that influenced patient survival included patient choice of modality, modified CCI, exchanges performed by family members, and age at the start of PD. Factors that influenced technique survival included patient choice of modality, modified CCI, and exchanges performed by family members. Age at the start of PD was not a significant factor influencing technique survival. Study 3: Most elderly PD patients were living with family; 7% were living alone. At the start of PD, 24% of elderly PD patients were covered by nursing-care insurance, including 11% of young elderly patients (65 – 74 years of age), 35% of old elderly patients (75 – 84 years of age), and 29% of very old elderly patients (85 years of age or older). Patients 75 years of age or older were covered by nursing-care insurance more frequently than were patients under 75 years of age. Nevertheless, at the start of dialysis, fewer than 10% of elderly patients were using nursing-care insurance for PD.

♦ Conclusions

In elderly patients, PD has good outcomes, especially in nondiabetic patients, in patients with few comorbidities, and in patients managing PD by themselves. In introducing dialysis in elderly patients, PD should be the treatment of choice. A more secure support system should be established to allow the elderly to choose PD treatment.

The Needs of Older Patients for Peritoneal Dialysis: Training and Support at Home

Chronic kidney disease (CKD) in all its stages has become an important problem for older patients, stage 3 - 5 is expected to happen in 25 to 30% of the population, and a higher prevalence can be found in residential care and nursing homes, affecting the demand for patient education. Although older patients are able and keen to learn, there are specific needs that must be addressed. The focus of this paper is to review the demands to train and maintain older patients on peritoneal dialysis (PD) at home.

Withdrawal from Dialysis and Palliative Care for Severely Ill Dialysis Patients in terms of Patient-Centered Medicine

We treated a dementia patient with end stage chronic kidney disease (CKD). The patient also had severe chronic heart disease and suffered from untreatable respiratory distress during the clinical course of his illness. We therefore initiated peritoneal dialysis therapy (PD) as renal replacement therapy, although we had difficulties continuing stable PD for many reasons, including a burden on caregivers and complications associated with PD therapy itself. Under these circumstances we considered that palliative care prior to intensive care may have been an optional treatment. This was a distressing decision regarding end-of-life care for this patient. We were unable to confirm the patient's preference for end-of-life care due to his dementia. Following sufficiently informed consent the patient's family accepted withdrawal from dialysis (WD). We simultaneously initiated nonabandonment and continuation of careful follow-up including palliative care. We concluded that the end-of-life care we provided would contribute to a peaceful and dignified death of the patient. Although intensive care based on assessment of disease is important, there is a limitation to care, and therefore we consider that WD and palliative care are acceptable options for care of our patients in the terminal phase of their lives.

Relationship between Icodextrin use and decreased level of small low-density lipoprotein cholesterol fractioned by high-performance gel permeation chromatography

Background

Because of the absorption of glucose in peritoneal dialysis (PD) solution, PD patients show an atherogenic lipid profile, which is predictive of poor survival in PD patients. Lipoprotein subclasses consist of a continuous spectrum of particles of different sizes and densities (fraction). In this study, we investigated the lipoprotein fractions in PD patients with controlled serum low-density lipoprotein (LDL) cholesterol level, and evaluated the effects of icodextrin on lipid metabolism.

Methods

Forty-nine PD patients were enrolled in this cross-sectional study in Japan. The proportions of cholesterol levels to total cholesterol level (cholesterol proportion) in 20 lipoprotein fractions were measured using an improved method of high-performance gel permeation chromatography (HPGPC).

Results

Twenty-six patients used icodextrin. Although no significant differences in cholesterol levels in LDL and high-density lipoprotein (HDL) were observed between the patients using icodextrin (icodextrin group) and control groups, HPGPC showed that the icodextrin group had significantly lower cholesterol proportions in the small LDL (t-test, p=0.053) and very small LDL (p=0.019), and significantly higher cholesterol proportions in the very large HDL and large HDL than the control group (p=0.037; p=0.066, respectively). Multivariate analysis adjusted for patient characteristics and statin use showed that icodextrin use was negatively associated with the cholesterol proportions in the small LDL (p=0.037) and very small LDL (p=0.026), and positively with those in the very large HDL (p=0.040), large HDL (p=0.047), and medium HDL (p=0.009).

Conclusions

HPGPC showed the relationship between icodextrin use and the cholesterol proportions in lipoprotein fractions in PD patients. These results suggest that icodextrin may improve atherogenic lipid profiles in a manner different from statin.

Exercise training for adults with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is a worldwide public health problem. In the National Kidney Foundation Disease Outcomes Quality Initiative guidelines it is stressed that lifestyle issues such as physical activity should be seen as cornerstones of the therapy. The physical fitness in adults with CKD is so reduced that it impinges on ability and capacity to perform activities in everyday life and occupational tasks. An increasing number of studies have been published regarding health effects of various regular exercise programmes in adults with CKD and in renal transplant patients.

OBJECTIVES

We aimed to: 1) assess the effects of regular exercise in adults with CKD and kidney transplant patients; and 2) determine how the exercise programme should be designed (e.g. type, duration, intensity, frequency of exercise) to be able to affect physical fitness and functioning, level of physical activity, cardiovascular dimensions, nutrition, lipids, glucose metabolism, systemic inflammation, muscle morphology and morphometrics, dropout rates, compliance, adverse events and mortality.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register, CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science, Biosis, Pedro, Amed, AgeLine, PsycINFO and KoreaMed. We also handsearched reference lists of review articles and included studies, conference proceeding's abstracts. There were no language restrictions.Date of last search: May 2010.

SELECTION CRITERIA

We included any randomised controlled trial (RCT) enrolling adults with CKD or kidney transplant recipients undergoing any type of physical exercise intervention undertaken for eight weeks or more. Studies using less than eight weeks exercise, those only recommending an increase in physical activity, and studies in which co-interventions are not applied or given to both groups were excluded.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of study and data quality were performed independently by the two authors. Continuous outcome data are presented as standardised mean difference (SMD) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

Forty-five studies, randomising 1863 participants were included in this review. Thirty two studies presented data that could be meta-analysed. Types of exercise training included cardiovascular training, mixed cardiovascular and resistance training, resistance-only training and yoga. Some studies used supervised exercise interventions and others used unsupervised interventions. Exercise intensity was classed as 'high' or 'low', duration of individual exercise sessions ranged from 20 minutes/session to 110 minutes/session, and study duration was from two to 18 months. Seventeen per cent of studies were classed as having an overall low risk of bias, 33% as moderate, and 49% as having a high risk of bias.The results shows that regular exercise significantly improved: 1) physical fitness (aerobic capacity, 24 studies, 847 participants: SMD -0.56, 95% CI -0.70 to -0.42; walking capacity, 7 studies, 191 participants: SMD -0.36, 95% CI-0.65 to -0.06); 2) cardiovascular dimensions (resting diastolic blood pressure, 11 studies, 419 participants: MD 2.32 mm Hg, 95% CI 0.59 to 4.05; resting systolic blood pressure, 9 studies, 347 participants: MD 6.08 mm Hg, 95% CI 2.15 to 10.12; heart rate, 11 studies, 229 participants: MD 6 bpm, 95% CI 10 to 2); 3) some nutritional parameters (albumin, 3 studies, 111 participants: MD -2.28 g/L, 95% CI -4.25 to -0.32; pre-albumin, 3 studies, 111 participants: MD - 44.02 mg/L, 95% CI -71.52 to -16.53; energy intake, 4 studies, 97 participants: SMD -0.47, 95% CI -0.88 to -0.05); and 4) health-related quality of life. Results also showed how exercise should be designed in order to optimise the effect. Other outcomes had insufficient evidence.

AUTHORS' CONCLUSIONS

There is evidence for significant beneficial effects of regular exercise on physical fitness, walking capacity, cardiovascular dimensions (e.g. blood pressure and heart rate), health-related quality of life and some nutritional parameters in adults with CKD. Other outcomes had insufficient evidence due to the lack of data from RCTs. The design of the exercise intervention causes difference in effect size and should be considered when prescribing exercise with the aim of affecting a certain outcome. Future RCTs should focus more on the effects of resistance training interventions or mixed cardiovascular- and resistance training as these exercise types have not been studied as much as cardiovascular exercise.