Peritoneal Dialysis International: Journal of the International Society for Peritoneal Dialysis

To analyze the relationship between lipoprotein(a) [Lp(a)] and fibrinogen as potential cardiovascular risk factors in patients on continuous ambulatory peritoneal dialysis (CAPD).

A total of 47 uremic patients receiving CAPD, 21 with coronary artery disease (CAD), 26 without CAD.

Lp(a) levels were determined by an immunoradiometric assay. Since Lp(a) serum concentrations vary depending on the size, apoprotein(a) [apo(a)] isoforms were determined (Westernblot). Fibrinogen was quantified according to Clauss.

The mean Lp(a) serum concentration was 43 ± 5 mg/dL (SEM) (median 33 mg/dL) in CAPD patients and 21 ± 2 mg/dL (8 mg/dL) in controls (p < 0.01). Patients with low molecular weight apo(a) isoforms exhibited substantially elevated Lp(a) levels when compared with patients with high molecular isoforms (p < 0.01). In addition, we found elevated fibrinogen levels in the CAPD patients (538 ± 61 mg/dL) compared with healthy controls (288 ± 46 mg/dL). Twenty-one CAPD patients (45%) were suffering from CAD. Patients with CAD had higher Lp(a) levels (54 ± 5 mg/dL vs 34 ± 4 mg/dL) as well as higher fibrinogen concentrations (628 ± 59 mg/dL vs 459 ± 46 mg/dL). Furthermore, a positive correlation between the fibrinogen levels and the Lp(a) serum concentration was observed (r = 0.45, p = 0.01).

We suggest that elevated Lp(a) levels are influenced by the allelic variation of the apo(a) isoform. In addition to the typical dyslipidemia found in CAPD patients, high levels of Lp(a) and fibrinogen may contribute to the elevated risk of coronary artery disease and other cardiovascular complications.

The aims of this study were to assess the clinical utility of total and regional bone densitometry in a large continuous ambulatory peritoneal dialysis (CAPD) population and to determine the clinical, biochemical, and radiographic variables that best identified osteopenic CAPD patients.

A cross-sectional study was performed on 45 CAPD patients (19 males, 26 females), comprising the total CAPD population at the Princess Alexandra Hospital.

Total body (TB), anteroposterior lumbar spine (APL), femoral neck (FN), Ward's triangle (WT), and skull bone mineral densities (BMDs) were measured using dual-energy x-ray absorptiometry (DEXA) and then correlated with clinical, biochemical, and radiographic indices of uremic osteodystrophy.

BMDs were not significantly different from age and sex-matched reference population data. Considerable regional variation of BMD Z scores were noted between FN (-0.11 ± 0.23), WT (-0.11 ± 0.22), and APL (1.22 ± 0.04) (p = 0.003). APLZ scores were significantly reduced in patients with a previous history of fracture (-1.36 ± 1.07vs0.89 ± 0.31), bonepain(-0.72 ± 1.08vs 1.01 ± 0.31), or steroid treatment (-0.62 ± 0.39 vs 1.16 ± 0.35). Increased BMDZ scores for APL (1.82 ± 0.57 vs0.38 ± 0.29, p < 0.05), FN (0.32 ± 0.36vs-0.38 ± 0.29, p =0.014), and WT (0.45 ± 0.38vs-0.45 ± 0.26, p <0.05) were found in patients with radiographic hyperparathyroid bone disease. Both APL BMD Z scores and skull BMDs were weakly correlated with PTH (r = -0.33, p < 0.05 and r = -0.33, p < 0.05, respectively) and with CAPD duration (r = 0.30, p < 0.05 and r = -0.30, p < 0.05). Generally, however, total body and regional BMDs were poorly related to age, renal disease type, dialysis duration, renal failure duration, serum aluminum, calcium, phosphate, alkaline phosphatase, osteocalcin, and parathyroid hormone.

We conclude that the prevalence of osteopenia is not increased in CAPD patients. Clinical and biochemical parameters do not reliably predict BMD measurements, but prior steroids and bone symptoms are major risk factors for important bone loss. Although DEXA can reliably detect osteopenia in different skeletal regions, its usefulness in detecting osteodystrophy is limited by the confounding effects of superimposed hyperparathyroid osteosclerosis, which increases BMD.

To identify the most advantageous formula for estimating creatinine clearance (CCr) and to establish a dose of dialysis that will ensure minimal acceptable levels of creatinine clearance in patients on continuous peritoneal dialysis (CPD).

Analysis of all CCr studies performed in CPD patients over 40 months.

All four dialysis units following CPD patients in one city. One dialysis unit is government-owned, one is university-affiliated, and two are community-based.

One hundred and ninety-four patients representing almost the entire CPD population in Albuquerque.

Creatinine and urea clearance studies were performed in 24-hour urine and drained dialysate samples. Creatinine clearance (peritoneal plus urinary) was normalized to either 1.73 m2 body surface area (CCr) or body water estimated by the Watson formulas (KT/V Cr). CCr and KT/Vcr were either corrected by averaging urinary creatinine and urea clearances or were not corrected. Two dialysis units were designated as the training set (92 patients, 143 clearance studies) and the other two units as the validation set (102 patients, 181 clearance studies).

Minimal acceptable creatinine clearance levels were determined in the training set by computing the creatinine clearance value corresponding to 1.70 weekly KTN urea by linear regression. Logistic regression models predicting low creatinine clearance were developed in the training set and were tested in the validation set.

The following weekly creatinine clearance values corresponded to 1.70 KTN urea: corrected CCr 52.0 L/1. 73 m2, uncorrected CCr 54.4 L/1.73 m2, corrected KT/Vcr 1.46, uncorrected KT/Vcr 1.53. Logistic regression identified as predictors of low creatinine clearance low daily urine volume (UV) and low daily dialysate drain volume/body water (DV/V) for all four creatinine clearance formulas, plus low/low-average peritoneal solute transport (only for uncorrected CCr) and serum creatinine (for both KT/Vcr formulas). In the validation set, the predictive models produced an area under the receiver operating characteristic (ROC) curve between 0.835 and 0.919 indicating very good predictive accuracy. For corrected CCr and anuria, the regression model produced a minimal normalized drain volume (DV/V) value consistent with minimal acceptable CCr equal to 0.305 L/L per 24 hours. This DV/V cutoff detected low corrected CCr in validation set anuric subjects (n = 55) with a sensitivity of 85% and a specificity of 71 %. For uncorrected CCr and anuria, DV/V cutoffs were 0.273 L/L per 24 hours (high/ high-average peritoneal solute transport) and 0.420 L/L per 24 hours (low/low-average transport). Sensitivity and specificity of these cutoffs in validation set anuric subjects were 87% and 85%, plus 86% and 33%, respectively.

The uncorrected CCr appears to be the most advantageous creatinine clearance formula in CPD, because it allows the use of peritoneal solute transport type in the calculation of the minimal required normalized drain volume. The minimal acceptable uncorrected CCr is 54.4 L/1. 73 m2weekly. To achieve this uncorrected CCr in anuria, the required minimal normalized drain volume is 0.273 L per liter of body water daily if peritoneal solute transport is high or high-average and around 0.420 L per liter of body water daily if peritoneal solute transport is low or low-average. The required total daily drain volume is computed by multiplying the required normalized drain volume by body water.

To review the outcome of renal transplantation in a group of patients treated with chronic peritoneal dialysis and to compare the results with those of a matched population on hemodialysis.

Retrospective study.

Tertiary, institutional hospital, administering to a population of two million, with 100 patients on peritoneal dialysis. Six hundred and sixty renal transplantations were performed by the end of 1993.

Fifty-six patients on chronic peritoneal dialysis who received 58 cadaveric renal allografts were compared to 58 patients on hemodialysis who received a graft from the same donor (n = 39), or the transplant next to the one performed to the corresponding patient on peritoneal dialysis (n = 19).

Patients on peritoneal dialysis showed a lower rate of delayed graft function (24.1 vs 50%, p < 0.05) and a similar incidence of acute rejection than patients on hemodialysis. Also, peritoneal dialysis patients received less supplementary immunosuppression, suffered a lower incidence of late infections (0.93 vs 0.58 episodes/patient), and had a similar incidence of dialysis-related complications (0.25 vs 0.20 episodes/patient).

Patients on peritoneal dialysis do well after renal transplantation. The incidence of some complications, particularly delayed graft function, is lower than in patients on hemodialysis, while the incidence of dialysis-associated complications is similar in both groups.

To review various aspects of the management of peritonitis due to Fusarium, a soil mold which infrequently causes infections in humans.

A case of Fusarium peritonitis in a child on chronic peritoneal dialysis (PD) is presented. The child developed Fusarium peritonitis 2 weeks after an episode of bacterial peritonitis. His Tenckhoff catheter was removed, and he was maintained on hemodialysis while receiving intravenous amphotericin. Following 2 weeks of treatment with amphotericin, he was successfully returned to PD. A literature review of all previously reported cases of Fusarium peritonitis was then conducted to determine features common to infections caused by Fusarium. Emphasis was also placed on unique characteristics of the organism that may affect patient management, as well as patient characteristics that may increase the risk for infection by Fusarium.

Fusarium may cause infection inimmuno suppressed individuals, such as cancer patients or patients on chronic PD. The organism has a propensity to attach to foreign bodies such as intravascular and intraperitoneal catheters. Therefore, successful treatment of infections caused by Fusarium may require catheter removal in addition to systemic antifungal therapy.

This report presents the first known case of Fusarium peritonitis in a child. In view of the difficulties posed by this unusual organism, optimal therapy of Fusarium peritonitis should consist of immediate catheter removal and treatment with systemic antifungal drugs.

To evaluate the degree of exposure to and the fate of di(2-ethylhexyl)phthalate (DE HP) and its major derivatives mono(2-ethylhexyl)phthalate (ME HP), 2-ethylhexanol (2-EH), and phthalic acid (PA) in patients undergoing regular continuous ambulatory peritoneal dialysis (CAPD) during a 4-hour dwell period.

Prospective, controlled.

Teaching hospital, Department of Nephrology.

Seven elderly patients on stable CAPD using Fresenius instruments and dialysate and 6 agematched healthy controls.

During a routinely performed peritoneal equilibration test (PET), blood and dialysate samples were drawn before and 120 and 240 min after the dwell was started. In addition, blood samples were taken from a group of volunteers participating in a pharmacological study.

Quantitative analysis of DE HP and its hydrolysis products was performed by selected ion-monitoring gas chromatography/mass spectrometry, operating the mass spectrometer in a combined positive and negative ion chemical ionization mode.

Serum concentrations of DE HP and PA were significantly higher in patients (median: 0.079 I1g/mL, range: 0.032 -0.210 I1g/mL; and 0.167 I1g/mL, range: 0.097 0.231 I1g/mL, respectively) than in controls [0.0195 I1g/mL, range: 0.016 -0.025I1g/mL (p = 0.0027) and 0.0120 I1g/mL, range: 0.006 -0.034I1g/mL (p = 0.0026), respectively]. Concentration of ME HP in the fluid of CAPD bags prior to use was four times higher than that of the parent compound. During the first 4 hours of dwell time, the concentrations of ME HP and 2-EH in dialysate consistently decreased from 0.177 (range: 0.137 -0.239119/ mL) to 0.022 I1g/mL (range: 0.005 -0.058 I1g/mL) (p = 0.017), and from 0.087 (range: 0.075 -0.097I1g/mL) to 0.05 I1g/mL (range: 0.023 0.064I1g/mL) (p = 0.017), respectively, while the concentration of DE HP remained stable. Remarkably high concentrations of PA (0.129 I1g/mL; range: 0.038 -0.466 I1g/mL) were found in CAPD bags prior to use, and these concentrations tended to increase during dwell time, without statistical significance, however (0.135I1g/mL; range: 0.073 -0.659I1g/mL, p = 0.062).

Patients on CAPD are regularly exposed to considerable amounts of phthalic ester derivatives, mainly to MEHPand PA. ME HP seems to bewellabsorbed by the peritoneal membrane. The long-term effects of this exposure remain to be elucidated.

The purpose of this study was to assess the reasons for treatment modality selection between hemodialysis (HD) and peritoneal dialysis (PD) in 150 consecutive patients in a single center.

This study is a retrospective study using chart review as the data collection method.

A single tertiary care university teaching hospital.

One hundred and fifty consecutive patients starting end-stage renal disease (ESRD) therapy at the Royal Victoria Hospital in Montreal were assessed. Their treatment modality at 6 weeks after starting dialysis was recorded as their treatment modality. Patients transplanted or who died prior to that 6 week period were excluded.

The treatment modality, that is, either HD or PD, at 6 weeks after the initiation of ESRD was the modality assigned to the patient.

One hundred and fifty patients started ESRD therapy of whom 83 went to HD and 67 to PD. Thirty-one patients were directed to HD, including 20 for social reasons, 3 with ostomies, and 6 with unsuitable abdomens. Fourteen patients were directed to PD, including 10 with severe cardiovascular disease, 3 with no vascular access, and one for geographical reasons. Of 31 diabetics who were encouraged to do PD, 17 went to PD and 14 to HD (10 for social reasons, 3 refused PD, and one with an inappropriate abdomen). Seventy-four patients were initially eligible for either PD or HD. Fifty percent (37) went to PD and 50% to HD. Of those going to HD, 15 went to self-care HD, of whom 7 had prior exposure to HD. Eleven were not informed regarding PD. There was no gender preference for PD versus HD.

We conclude that among informed patients, if given a choice of treatment modality, the majority will choose self-care dialysis including continuous ambulatory peritoneal dialysis (CAPD) or selfcare HD.

To test the reliability of creatinine clearance in children on peritoneal dialysis (PD).

Longitudinal, case-controlled.

Routine clinic visits at the pediatric dialysis unit of the Universitätskinderklinik of Vienna. Patients: Eleven children (2 -13 years, 10 -55 kg) with end-stage renal disease on PD.

Creatinine clearance (CCr) was determined by measuring creatinine excretion (ECr) over 24 hours in both dialysate and urine. Each child had three to five separate measurements of their CCr. At the same time we also calculated the schwartz formula clearance from the patient's height and serum creatinine, using a modified correlate.

Reliability of CCr was assessed by two approaches. First, we compared each serial measurement with the mean value for each patient and thereby assessed the “intramethodical” variability. Second, we compared each CCr with the simultaneous formula clearance and assessed the “intermethodical” disagreement.

Twenty-seven percent of the measurements of CCr were classified as unreliable based on a comparison with the mean value for each patient. Reliability was closely correlated with residual renal function (p < 0.01); only 12% of the measurements in the an uric patients were classified as unreliable (vs 31% in the patients with residual renal function). The simultaneous formula clearance was less variable than the CCr. The formula clearance had a sensitivity of 93% and a specificity of 60% for detecting unreliable values of CCr.

Estimation of total CCr is unreliable in pediatric patients on PD. A simultaneous formula clearance can be used to detect which values are unreliable.