Protein-losing enteropathy is associated with peritoneal functional abnormalities in peritoneal dialysis patients.

OBJECTIVE: To evaluate the relationship between acquired peritoneal transport disorders and the presence of protein-losing enteropathy (PLE), and their contribution to the protein malnutrition in peritoneal dialysis (PD) patients. PATIENTS AND METHODS: We studied 31 clinically stable PD patients that received a fat overload diet for 3 days. We measured intestinal absorption of fecal fat (normal < 6 g/24-hour stool) and nitrogen (normal < 2 g/24-hr stool), intestinal protein permeability [fecal clearance of alpha1-antitrypsin (Calpha1AT) (normal < 12 mL/24-hr stool)], and nutritional markers [normalized protein nitrogen appearance (nPNA), half-life medium-term proteins, and body mass index]. Peritoneal solute transport was measured by mass transfer coefficient (MTC), and water transport by peritoneal ultrafiltration (UF) capacity. To define protein maldigestion it was necessary to find high fecal nitrogen values with normal Calpha1AT; PLE was defined when both values were elevated. RESULTS: High fecal nitrogen (mean 2.1+/-1 g/24-hr stool) and fat (mean 5.8+/-3.6 g/24-hr stool) were found in 15 patients; 6 patients had high Calpha1AT levels (PLE).These 6 patients showed a worse nutritional status: lower albumin (3.57+/-0.57 g/dL vs 3.98+/-0.38 g/dL, p < 0.05) and transferrin (243+/-70 mg/dL vs 272+/-44.3 mg/dL, p < 0.05), as well as lower triglycerides (131.3+/-31.7 mg/dL vs 187+/-116 mg/dL, p< 0.05). Higher urea MTCs were found in 10 patients, normal in 7, and lower in 14. Higher creatinine MTCs were found in 8 patients, normal in 15, and lower in 8. Normal peritoneal UF capacity was found in 25 and lower in 6 patients. These 6 patients showed higher urea and creatinine MTCs and Calpha1AT. A positive linear correlation between Calpha1AT, urea MTC (r = 0.56, p < 0.01), and creatinine MTC (r = 0.46, p < 0.01) was found. A similar situation occurred between Calpha1AT, fecal fat (r = 0.45, p < 0.05), and fecal nitrogen (r = 0.43, p < 0.05). Thirteen patients with previous history of peritonitis showed higher Calpha1AT than those without peritonitis (10.2+/-8 mL/24-hr stool vs 5.2+/-4.4 mL/24-hr stool, p < 0.05). CONCLUSIONS: We confirm that protein and fat malabsorption, maldigestion, and PLE are present in some PD patients. Higher fecal Calpha1AT is associated with malnutrition and poorer showings of the viability markers of peritoneal membrane function.     

腹膜透析患者低白蛋白血症对其左心室结构和功能的影响

目的：探讨腹膜透析(PD)患诸因素对左心室结构和功能的影响。方法：20例PD患，所有患进行超声心动图与心功能检测，并根据Devereux公式计算左心室心肌重量指数(LVMI)。将患的年龄、PD时间、Kt／v、Hb、TG、Tch、血浆白蛋白(SA)、nPCR、CBP、PTH、PD超滤量与左心室射血分数(EF)、LVMI和左心室舒张早期和晚期最大血流速度比(E／A)进行逐步回归分析。患的收缩压与LVMI，CRP、nPCR分别与SA作直线相关分析。结果:LVH发生率为55％，E／A＜1占95％，逐步回归分析显示：SA与LVMI呈显负相关(r^2=0．3619，P=0．005)，年龄与E／A呈负相关(r^2＝0．58，P=0．0245)。直线相关分析示收缩压与LVMI呈正相关。CRP与SA呈显负相关，nPCR与SA呈正相关。SA＜30g／L，LVH发生率为73％，较高于SA≥30g／L，左心室舒张功能障碍前较后为多。结论:PD患LVH发生率高，低白蛋白血症是值得关注的重要危险因素之一。     

Relationship between dialysis adequacy and quality of life in long-term peritoneal dialysis patients.

OBJECTIVE: The purpose of this study was to compare quality of life (QOL) between peritoneal dialysis (PD) patients with adequate and inadequate total solute clearance (TSC). We also tried to determine the relationship between QOL and TSC. DESIGN: A cross-sectional study design was used in which QOL was evaluated and compared between PD patients with adequate and inadequate TSC. SETTING: The PD unit of a university teaching hospital. PATIENTS: Sixty-seven patients were recruited, 38 on continuous ambulatory PD and 29 on continuous cyclerassisted PD. METHODS: Patients were divided into adequate and inadequate groups, based on the results of either total urea clearance (Kt/Vurea) or total creatinine clearance (weekly CCr). The demographic data, dialysis variables, and clinical parameters of these patients were all collected. QOL was evaluated using the SF-36 questionnaire, which contains eight domains and is a comprehensive and validated instrument for QOL evaluation. QOL of patients in adequate and inadequate groups was compared. The relationship between QOL and TSC was also examined. RESULTS: Among patients grouped by Kt/Vurea, patients in the adequate group had significantly higher scores in two domains of the SF-36, that is, physical and emotional role functioning, than did those in the inadequate group. The total SF-36 scores were positively correlated with Kt/Vurea when all patients were pooled together. However, among patients grouped by weekly CCr, there was no significant difference in any of the eight domains of the SF-36 between patients in the adequate and inadequate groups. No correlation was found between the total SF-36 scores and weekly CCr. CONCLUSION: Our study had two important findings: First, PD patients with adequate total solute clearance, based on Kt/Vurea and not on weekly CCr, had a better QOL. Second, Kt/Vurea is better correlated with QOL than weekly CCr. These findings suggest that Kt/Vurea is a better parameter for the clinical evaluation of total solute clearance from the viewpoint of QOL.     

Clinical factors associated with sodium removal in peritoneal dialysis patients

A cross-sectional study was conducted in 156 clinically-stable peritoneal dialysis patients to identify the factors associated with sodium removal. Serum biochemistry, peritoneal function (modified peritoneal equilibration test [PET]) and the adequacy of dialysis were analysed in relation to sodium removal using multivariate linear regression. Factors significantly affecting peritoneal sodium removal included infusion volume and ultrafiltration volume per 24 h, sodium dip in the first hour of PET and sodium difference between serum and fresh dialysate. Factors significantly affecting total sodium removal included ultrafiltration and urine volume per 24 h, sodium dip in the first hour of PET and sodium difference between serum and fresh dialysate. With traditional dialysate, adequate fluid removal is required to ensure sufficient sodium removal, but a low-sodium dialysate may prevent sodium retention. Sodium removal should be included in evaluation of the adequacy of dialysis.     

腹膜转运类型对腹膜透析患者B型脑钠肽和心脏结构及功能的影响

目的探讨腹膜透析患者腹膜转运类型和B型脑钠肽（B-typenatriureticpeptide,BNP）及心脏结构与功能的关系。方法腹膜透析患者64例,根据腹膜平衡试验结果分为高转运组39例与低转运组25例,比较2组患者透析时间、合并糖尿病、高血压比例,检测2组血白蛋白、血红蛋白、血尿素氮、肌酐与BNP值,彩超测定患者左心房前后径、左心室前后径、室间隔厚度、左心室后壁厚度及左室射血分数,并进行比较。结果高转运组合并糖尿病比例、室间隔厚度、BNP均值（64．1％,（11．16±1．10）mm,578ng／L）高于低转运组（36．0％,（10．22±1．23）mm,312ng／L）（P〈0．05）,白蛋白、左室射血分数（（32．51±4．95）g／L,（59．85±5．10）％）低于低转运组（（35．95±4．84）g／L,（62．48±5．05）％）（P〈0．05）。结论与低转运类型腹膜透析患者相比,高转运类型腹膜透析患者容量负荷较高,心脏功能与营养状况较差;糖尿病患者腹膜转运类型多为高转运或高平均转运型。     

Recovery of renal function and the discontinuation of dialysis in patients treated with continuous peritoneal dialysis.

OBJECTIVE: Previous studies have shown that patients with end-stage renal disease (ESRD) treated with continuous peritoneal dialysis (CPD) have better preservation of endogenous renal function than patients treated with hemodialysis (HD). We wondered if this better preservation of endogenous renal function seen with CPD patients translates into the improved likelihood of recovery of endogenous renal function in those patients with potentially reversible causes of renal failure. METHODS: To evaluate this question, we reviewed the records of all 1200 patients that completed CPD training at a large, freestanding peritoneal dialysis center in New Haven, Connecticut, between 1979 and 1999, and the records of all patients completing CPD training in New England between 1993 and 1998. In New Haven, about half the new patients with ESRD were started on CPD compared to only 15% in New England. We then compared the chances of recovery of renal function in these two cohorts of CPD patients to the chances of recovery of renal function in two groups of HD patients. The first group consisted of all patients that started on HD in New England between 1993 and 1998.The second group consisted of all patients that started HD in our HD unit in New Haven, Connecticut, between 1993 and 1999. The data on the New England patients were provided by the ESRD Network of New England. All patients entered into the present study had to have been on dialysis for a minimum of 3 months, as in the United States Renal Data System database, and had to have recovered sufficient renal function to be able to be maintained off dialysis for a minimum of 30 days. RESULTS: 29 of 1,200 CPD patients (2.4%) trained in New Haven recovered sufficient renal function to permit the discontinuation of dialysis for a minimum of 30 days. In comparison, only 305 of 19,032 patients (1.6%) managed with HD in New England (p < 0.05 compared to New Haven CPD patients) and 3 of 430 patients (0.7%) in our HD center (p < 0.05 compared to New Haven CPD patients) recovered sufficient glomerular filtration rate (GFR) to allow the discontinuation of dialysis for at least 30 days. If only those CPD patients that initiated dialysis between 1993 and 1999 in New Haven were analyzed, 15 of 369 (4.1%) recovered sufficient GFR to allow discontinuation of dialysis for at least 30 days (p < 0.025 compared to both groups of HD patients). Of the 2,924 patients completing CPD training in New England, 60 (2.1%) recovered renal function; this percentage is not significantly different from the percent of HD patients in New England recovering renal function. CONCLUSION: Although the present study is a retrospective study and the actual criteria for selection of CPD and HD therapy are not controlled for, the data raise the question of whether there may be a therapeutic advantage to treating newly diagnosed ESRD patients, that have a potentially reversible cause of renal failure, with CPD.     

Bleeding complications associated with peritoneal dialysis catheter insertion.

OBJECTIVE: To identify the incidence of bleeding complications associated with peritoneal dialysis catheter insertion. DESIGN: Retrospective review at a tertiary-care center of all double-cuffed Tenckhoff catheters placed surgically from 1 January 1992 to 1 October 2003 to identify the incidence of major bleeding complications occurring with catheter insertion. Major bleeding episodes were defined as > or = 3% decline in hematocrit, or the need for surgical intervention or blood transfusion within 2 weeks of insertion. RESULTS: 292 catheters had been inserted in 263 patients. Six patients satisfied the criteria for a major bleeding event, for a major bleeding complication rate of 2%. Bleeding was associated with perioperative anticoagulation in 3 patients, uremia and thrombocytopenia in 1 patient, aspirin use and thrombocytopenia in 1 patient, and 1 patient experienced intraoperative bleeding. Coagulation parameters were not obtained prior to the procedure in 2 of the 6 patients. CONCLUSION: The rate of serious bleeding complications related to catheter insertion is low and usually associated with anticoagulation. Holding anticoagulation therapy for a minimum of 24 hours during the postoperative period should eliminate much of the risk. Coagulation parameters should also be obtained and corrected preoperatively.     

Factors associated with sleep disorders in Chinese patients on continuous ambulatory peritoneal dialysis.

OBJECTIVE: This study aimed at identifying factors that are associated with sleep disorders in Chinese patients on continuous ambulatory peritoneal dialysis (CAPD). STUDY DESIGN: Questionnaire survey. SETTING: Renal dialysis unit of a tertiary-care hospital. PATIENTS: 179 Chinese patients on CAPD. MAIN OUTCOME MEASURES: The quantity and quality of sleep were compared between CAPD patients with and without self-reported sleep disorders. Demographic variables, personality traits, behavioral factors, somatic symptoms, and clinical parameters were correlated with the presence of sleep disorders. RESULTS: The mean age of the patients was 61 +/- 12 years and the male-to-female ratio was 1:1.3. The mean duration of CAPD was 47 +/- 42 months. 110 patients (61%) had self-reported sleep disorders. Among patients with self-reported sleep disorders, difficulty falling asleep was the most frequent complaint (74.5%), followed by frequent awakening (68%) and early morning waking (68%). The mean duration of sleep among these patients was 4.6 +/- 2.2 hours, versus 7.3 +/- 1.4 hours in patients without self- reported sleep disorders. Three personality traits (anxiety, worry, and sadness) and two somatic symptoms (bone pain and arthralgia) were the factors significantly associated with sleep disorders. Patients with sleep disorders also more frequently reported certain symptoms suggestive of sleep apnea. Demographic variables, behavioral factors (e.g., caffeine or alcohol intake), and clinical parameters (e.g., adequacy of dialysis, body mass index, hemoglobin, albumin, parathyroid hormone levels) did not differ between patients with and without sleep disorders. CONCLUSIONS: Sleep disorders are prevalent among Chinese CAPD patients. Personality traits (anxiety, worry, and sadness) and somatic symptoms (bone pain and arthralgia) were the factors significantly associated with sleep disorders in this patient population. Behavioral factors, demographic variables, and clinical parameters did not appear to predict sleep disorders. Further studies evaluating the impact of various psychological factors on sleep disorders among CAPD patients are warranted.     

泌尿系统疾病多学科交叉研究专题维持性腹膜透析患者远期预后的影响因素分析

目的 分析维持性腹膜透析(PD)患者远期预后的影响因素.方法 回顾性分析2006年1月-2015年8月南京鼓楼医院收治的209例PD患者的临床资料,计算生存率及技术生存率,分析影响预后的危险因素.11例PD患者治疗5年内行肾移植,根据透析龄将其余患者分为长期PD组110例(透析龄≥5年)和短期PD组88例(透析龄＜5年...     

Acute systemic inflammation is associated with an increase in peritoneal solute transport rate in chronic peritoneal dialysis patients.

BACKGROUND: This study was performed to evaluate the effects of acute systemic inflammation on peritoneal solute transport rate (PSTR) in chronic peritoneal dialysis (CPD) patients. METHODS: A baseline standard peritoneal equilibration test (PET) was performed on each patient every 6 months, and blood concentration of high-sensitivity C-reactive protein (hs-CRP) was assayed every 2 months in our peritoneal dialysis clinic. Acute systemic inflammation was defined as a greater than 10-fold increase in hs-CRP concentration compared with baseline value, in the absence of peritonitis, and returning to baseline level in 2 months. In patients with acute systemic inflammation, PET and hs-CRP concentration assays were performed during inflammation and after recovery. Ten patients with acute systemic inflammation were enrolled in the inflammation group and 42 other patients served as controls. RESULTS: There were no significant changes in hs-CRP and dialysate-to-plasma ratio of creatinine (D/Pcreat) in the control group during the study period. In the inflammation group, median hs-CRP levels at baseline, during acute inflammation, and at recovery were 2.3 mg/L (range 0.3 - 4.5 mg/L), 39.2 mg/L (range 15.1 - 117.4 mg/L), and 3.7 mg/L (range 0.9 - 8.9 mg/L), respectively. Median D/Pcreat increased significantly from baseline (0.64; range 0.55 - 0.98) to time of acute inflammation (0.72; range 0.60 - 0.96) (p < 0.05). The D/Pcreat at recovery was 0.67 (range 0.52 - 0.94), which decreased significantly from time of acute inflammation (p < 0.05). There was no correlation between changes in log (hs-CRP) and changes in D/Pcreat. CONCLUSION: We have shown here that acute systemic inflammation is associated with a temporary increase in PSTR in CPD patients.     

High peritoneal permeability is not associated with higher mortality or technique failure in patients on automated peritoneal dialysis.

BACKGROUND: Patients on continuous ambulatory peritoneal dialysis (CAPD) who have high small-molecule peritoneal transport have increased mortality. OBJECTIVE: To investigate the impact of baseline peritoneal transport characteristics on patient and technique survival in incident peritoneal dialysis (PD) patients, most of whom are on automated PD (APD), with the use of icodextrin. DESIGN: Retrospective observational cohort study. SETTING: A single PD unit. Patients and METHODS: 193 new patients that began PD between January 2000 and September 2004, and had an initial peritoneal equilibration test within 6 months of commencement of PD. Patients were divided into low (L), low average (LA), high average (HA), and high (H) peritoneal transport groups. Death-censored technique failure and patient survival were examined. RESULTS: Of the 193 patients, 151 (78.1%) were on APD or on APD with icodextrin or on CAPD with icodextrin. At the end of 1, 3, and 5 years, patient survival was 91%, 82%, and 67% in LA group; 95%, 77%, and 69% in HA group; and 96%, 71%, and 71% in H group. Technique survival was 100%, 90%, and 77% in LA group; 96%, 84%, and 72% in HA group; and 92%, 87%, and 77% in H group. High peritoneal permeability did not predict worse patient survival or technique failure, while age, diabetes, a lower glomerular filtration rate, and high body mass index (> or =30 kg/m(2)) were independent predictors of death. CONCLUSION: This study suggests that higher peritoneal transport is not a significant independent risk factor for either mortality or death-censored technique failure. The favorable outcome for high transporters in this study may be due to improved management of volume status by the increased use of APD and the use of icodextrin-based dialysis fluid.