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ABSTRACT: Continuous ambulatory peritoneal dialysis (CAPD) has been considered as a more efficient modality for sodium removal than automated peritoneal dialysis (APD), due to the longer dwell times and the sodium sieving phenomenon. However, because studies regarding sodium removal in peritoneal dialysis (PD) report rather controversial results and carry various methodological flaws, it remains uncertain whether they offer enough significant information regarding PD prescription and therapy. The aim of the present observational cross-sectional study was to evaluate the impact of the optimal prescription of CAPD and APD, regarding solute clearances and daily ultrafiltrate, on daily sodium removal. Forty-six (46) patients aged 52.3 ± 14 years were studied. Twenty-six (26) patients were subjected to CAPD, and 20 patients were subjected to APD. Ten (10) patients per group were prescribed icodextrin for the long dwell to achieve optimal adequacy and ultrafiltration (UF) targets. CAPD patients removed a higher, albeit not statistically significant, daily amount of sodium (131.7 ± 98.2 mmol) compared with APD patients (79.4 ± 129.2 mmol). Their Kt/V urea was lower (1.48 ± 0.3 vs. 2.17 ± 0.33, P < 0.05), and there were no differences on daily UF (1119 ± 533 vs. 1005 ± 517 mL). In both groups, icodextrin use for the long dwell resulted in equal sodium removal with that of patients not prescribed icodextrin. Our results, derived from an unselected PD population, indicate that although classic CAPD may be more efficient for sodium removal than APD, the use of icodextrin as an adjuvant for higher daily UF not only increases solute clearance but also removes more sodium for both modalities. In addition, calculations of sodium removal in PD do not seem to benefit the everyday clinical practice, provided that PD patients can achieve the adequacy targets and present optimal daily UF without signs of volume overload.
Artificial Organs 03/2013; · 2.00 Impact Factor
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ABSTRACT: Mechanical problems of the Peritoneal Dialysis (PD) catheter remain a significant cause of temporary or even permanent transfer to hemodialysis. Until recently, the most popular approach was to remove the problematic PD catheter than to try to salvage it. We report a case of severe (two-way) PD catheter obstruction that appeared after spontaneous hemoperitoneum and did not resolve with multiple conservative measures. However, it was successfully salvaged by laparoscopic surgery and milking of a big intraluminal clot.
Seminars in Dialysis 09/2012; · 2.27 Impact Factor
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ABSTRACT: Recent studies indicate that regulatory T-cells (Tregs) promote transplant tolerance. We studied Treg levels in 39 stable renal transplant recipients to determine the sizes of the Treg populations and the effects of treatment regimens thereof.
All patients (19 with good graft function and 20 with chronic allograft nephropathy) received induction therapy (basiliximab) and were on triple immunosuppressive regimens with calcineurin inhibitors (cyclosporine or tacrolimus), mycophenolate mofetil (MMF) or everolimus and steroids. Twenty healthy subjects served as controls. Whole blood samples were stained with anti-CD4, CD25, CD127, and FoxP3 antibodies and analyzed by flow cytometry to determine CD4+CD25(high)FoxP3+/- and CD4+ CD25(high)CD127(-/low) Treg levels.
All patients had significantly reduced CD4+CD25(high)FoxP3+/- but no CD4+ CD25(high)CD127(-/low) Treg levels compared to controls. Renal allograft function did not correlate with Treg levels. Statistically significant correlations between CD4+CD25(high)Foxp3+ Tregs and tacrolimus levels and CD4+CD25(high)Foxp3- Tregs and HLA-DR mismatching were detected. Patients receiving MMF had significantly higher CD4+CD25(high)Foxp3+ Tregs compared to patients on everolimus who were also receiving lower doses of calcineurin inhibitors.
Overall, immunosuppression lowers CD4+CD25(high)FoxP3+/- Treg levels significantly in the periphery in renal transplant recipients. In addition, different immunosuppressive regimens have different impacts on CD4+CD25(high)FoxP3+ Tregs, a fact that may influence long-term allograft survival.
American Journal of Nephrology 01/2010; 32(1):1-9. · 2.54 Impact Factor
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ABSTRACT: Hospital-based intermittent peritoneal dialysis (IPD) is an old PD modality applied for as long as 40 h per week using high volumes of PD fluid, but it has almost been abandoned due to its low solute clearances. However, IPD might be the only option for elderly dialysis patients with significant comorbidities, unable to undergo haemodialysis (HD) or PD at home without any assistance, for various reasons.
We describe our experience with 25 patients aged 71.2 +/- 7.5 years with a previous history of HD for 55.4 +/- 54 months, dialysed with IPD for more than 3 months. IPD was performed three times weekly for 8-10 h.
Mean values for haematocrit, serum urea, creatinine, sodium, potassium and calcium were comparable with other ESRD populations, whereas there were significantly lower values for albumin (3.2 +/- 0.3 mg/dL) and significantly higher values for phosphorus (7.1 +/- 1.7 mg/dL) despite the use of phosphate binders. The patients survived for a mean of 16.8 +/- 11.5 (3-43) months despite very low solute clearances, as expressed by Kt/V urea (1 +/- 0.26) and weekly creatinine clearance (27.2 +/- 7.6 L/week). However, by using 22.9 +/- 4.5 L of various combinations of isotonic and hypertonic PD fluids, the mean ultrafiltrate was 1854 +/- 326 mL per session. There were only two cases of peritonitis, unrelated to IPD per se.
Considering the underlying comorbidities, IPD remains a valuable and effective option with acceptable survival rates, for a special population of ESRD patients not able for various reasons to undergo HD, neither PD at home.
Nephrology Dialysis Transplantation 07/2009; 24(10):3215-8. · 3.40 Impact Factor
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Journal of Clinical Hypertension 03/2009; 11(2):111. · 1.83 Impact Factor
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American Journal of Clinical Nutrition 01/2009; 89(1):436; author reply 436-8. · 6.67 Impact Factor
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New England Journal of Medicine 11/2008; 359(16):1731; author reply 1731-2. · 53.30 Impact Factor
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JAMA The Journal of the American Medical Association 11/2008; 300(14):1648; author reply 1648-9. · 30.03 Impact Factor
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Nephrology Dialysis Transplantation 08/2008; 23(10):3365-6. · 3.40 Impact Factor
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ABSTRACT: One of the main goals of dialysis is the control of extracellular volume, because inadequate sodium and fluid removal result in fluid overload and increased mortality. In the present study, we evaluated the roles of continuous ambulatory peritoneal dialysis (CAPD), continuous cycling peritoneal dialysis (CCPD), and the use of icodextrin on sodium removal in 29 patients (n = 18 on CAPD, n = 11 on CCPD). Daily removal of sodium by each modality and dialysis adequacy by Kt/V and creatinine clearance were evaluated. A significantly higher amount of sodium was removed in CAPD patients than in CCPD patients, although peritoneal dialysis clearances were lower in CAPD, and no difference in daily ultrafiltration was observed between the modalities. In the CAPD group, patients using icodextrin for the long dwell showed significantly increased 24-hour sodium removal (218 +/- 65 mmol/L) as compared with patients not using icodextrin (96.3 +/- 58 mmol/L, p < 0.001); they also showed increased daily ultrafiltration (1685 +/- 302 mL vs. 717 +/- 440 mL, p < 0.001). In the CCPD group, 8 patients were using icodextrin for the long dwell, and they showed significantly increased sodium removal only for the day exchange (43 +/- 49 mmol/L) as compared with patients not using icodextrin (-60 +/- 6, p < 0.001). Hypertension was less common in the CAPD patients than in the CCPD patients. These results indicate that CAPD is a more efficient modality than CCPD for sodium removal. Icodextrin is an effective tool not only for increasing adequacy, but also for removing more sodium in both modalities.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/2008; 24:27-31.
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ABSTRACT: Idiopathic membranous nephropathy, the most common cause of nephrotic syndrome in adults, has been traditionally treated with corticosteroids and cytotoxic drugs. Ciclosporin A (CsA) is used in resistant cases, but also as a first-line treatment, due to the serious side effects of cytotoxic drugs. In this study, the remission rates of nephrotic syndrome and the incidence of side effects of corticosteroids and low CsA doses are compared with those after treatment with cytotoxic drugs.
Seventy-seven nephrotic patients with well-preserved renal function who were treated with methylprednisolone and CsA (n = 46) or cytotoxic drugs (n = 31) were studied. The effects of treatments were estimated on the basis of remission rates of nephrotic syndrome and preservation of the renal function.
Remission (complete or partial) of nephrotic syndrome was observed in 85% of the patients treated with CsA and in 55% of the patients treated with cytotoxic drugs (p < 0.01). Deterioration of the renal function, more common in patients with multiple relapses and interstitial fibrosis, was observed in 26 and 23% of the patients, respectively (p = NS). Serious side effects and discontinuation of treatment were more frequent in patients treated with cytotoxic drugs (10 vs. 4%).
The combination of corticosteroids with CsA represents a better regimen for patients having idiopathic membranous nephropathy, since it is associated with higher remission rates of nephrotic syndrome and less severe side effects than corticosteroids and cytotoxic drugs.
American Journal of Nephrology 01/2007; 27(3):226-31. · 2.54 Impact Factor
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Nephrology Dialysis Transplantation 02/2006; 21(1):236-7. · 3.40 Impact Factor
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ABSTRACT: Metabolic acidosis correction is one of the goals of renal replacement therapy. Correction of acidosis in peritoneal dialysis (PD) may be affected by PD modalities such as automated PD (APD) or by new solutions containing a combination of bicarbonate and lactate as a buffer [bicarbonate continuous ambulatory PD (CAPD)]. The aim of the present study was to examine the acid-base status of our PD population and to compare the effects of APD, lactate CAPD, and bicarbonate CAPD on serum bicarbonate levels. We studied 35 stable patients undergoing APD (n = 15), lactate-buffered (35 mEq/L) CAPD (n = 14), and bicarbonate/lactate-buffered CAPD (n = 6) for 48.5 +/- 38.1 months. Most of our patients had serum bicarbonate levels in the normal range. In 3 patients (8%), HCO3 was below 22 mEq/L, and in 8 patients (22%; APD = 2, lactate CAPD = 2, bicarbonate CAPD = 4), HCO3 was above 28 mEq/L. We found no statistically significant correlations between HCO3 serum levels and PD prescription, peritoneal membrane characteristics, or intake of calcium carbonate and sevelamer hydrochloride. Patients on bicarbonate CAPD had higher HCO3 serum levels, but this difference disappeared when corrections for duration of dialysis, residual urine volume, and PD adequacy indices were applied. In the studied PD population, adequate correction of metabolic acidosis was achieved, as reflected in serum bicarbonate levels. We observed no difference in serum bicarbonate levels between APD and lactate CAPD patients. The new bicarbonate-buffered PD solutions are more biocompatible and can result in higher serum bicarbonate levels. However, a significant number of PD patients on bicarbonate-buffered solutions may become alkalotic. The clinical significance of these results needs further examination in prospective studies.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/2006; 22:187-91.
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ABSTRACT: The timing of the first episode of peritonitis in peritoneal dialysis (PD) might have some special characteristics and may depend on many factors such as a patient's attitudes, age, comorbidity, or training capacity. It may also have a significant impact on further peritonitis episodes and technique failure. We retrospectively analyzed data for 168 PD patients who were undergoing continuous ambulatory PD by a twin-bag system, automated PD, or in-center intermittent PD over 12 years. There were 121 cases of peritonitis recorded in 60 patients, with an overall peritonitis rate of 1 episode per 45.75 patient-months. The mean time to the first episode of peritonitis after commencement of PD was 26.4 +/- 22 months (range: 1-110 months). In 20 patients, a first peritonitis episode presented rather early--during the first 12 months on PD (group A)--and in 27 patients, a first episode presented rather late-after at least 24 months on PD (group B). Group A had lower technique survival (30.4 +/- 26.5 months), were more prone to further episodes of peritonitis during follow-up, and had a total peritonitis rate of 1 episode per 14.85 patient-months. In group B, technique survival was longer (69.3 +/- 33.8 months), and the total peritonitis rate was 1 episode per 45.68 patient-months. We observed no differences between the two groups in comorbidity, age, or PD modality. These results indicate that patients with early-onset peritonitis are prone to making mistakes during connection, resulting usually in infection with gram-positive pathogens. These patients may present repeated peritonitis episodes and experience decreased technique survival.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/2006; 22:50-4.
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ABSTRACT: Long-term exposure of peritoneal membrane to bioincompatible dialysis solutions leads to structural changes and loss of ultrafiltration capability.
We studied the possible relationship between histologic change and the transport characteristics of peritoneal membrane and adequacy of dialysis in continuous ambulatory peritoneal dialysis (CAPD) patients. Patients and
The study included 18 CAPD patients (11 men, 7 women) who underwent a peritoneal biopsy either at initiation of treatment (group A, n = 9) or after a mean of 4 years on CAPD (group B, n = 9). The morphologic changes in the mesothelial cells and the vascular compartment and the thickness of the submesothelial collagenous zone were estimated and compared with observations from 6 patients with normal renal function who underwent biopsy of the parietal peritoneum during abdominal surgery. The relationship of the observed changes in CAPD patients to results from a peritoneal equilibration test (PET) and to adequacy of dialysis [total weekly creatinine clearance (CCr) and Kt/V urea] were also investigated.
The main histologic changes in both groups of patients were loss of mesothelial cells and decrease in the normal mesothelial surface, thickening of the submesothelial collagenous zone, and presence of vascular hyalinosis. The thickness of the submesothelial collagenous zone in both groups of patients was significantly greater than that found in controls (410 mum and 580 mum vs 50 mum, p < 0.05). Although no significant difference was found between morphologic change in the peritoneal membrane of uremic patients starting on CAPD and those who had been on peritoneal dialysis (PD) for a mean period of 4 years, a trend was observed toward more severe lesions in the latter patients. The PET, CCr, and Kt/V urea were not significantly different in the two groups of patients. Those parameters also showed no significant changes when examined at initiation of CAPD and after a mean of 4 years of PD in the same patients (group B). No significant correlations were observed between the histologic changes and the PET, CCr, or Kt/V in both groups of patients.
Significant structural changes are observed in the peritoneal membrane of uremic patients, and those changes become worse with CAPD treatment. Structural changes are not followed by functional changes during the first 4 years on CAPD.
Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis. 12/2003; 23 Suppl 2:S26-30.
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ABSTRACT: Background. The purpose of the study was to investigate the rigidity of polymorphonuclear leukocytes (PMNs) in non‐dialysed chronic renal failure (CRF) and haemodialysis (HD) patients. Methods. PMN rigidity as well as tumour necrosis factor α (TNF‐ α ) and interleukin 1 β (IL‐1 β ) plasma levels were assessed in 10 early‐stage CRF, 10 late‐stage non‐HD, and 10 HD patients, before and during dialysis. In HD patients both cellulose acetate and polysulphone membranes were used. Ten healthy subjects served as controls. Rigidity was tested by counting the deformability in morphologically passive PMNs by the micropipette method. Cytokine levels were measured by enzyme‐linked immunosorbent assay. Results. PMN rigidity was significantly increased in end‐stage CRF patients regardless of HD but not in early‐stage CRF. In HD patients PMN rigidity increased significantly 60 min after initiation of HD. There was an increase of TNF‐ α and IL‐1 β levels in end‐stage non‐HD and HD patients and a further increase at 60 min after initiation of HD. The percentage of morphologically activated PMNs was increased only during dialysis. The nature of the HD membrane had no influence on rigidity, PMN activation, or cytokine production. Conclusions. The results indicate that PMN rigidity is defective in end‐stage chronic CRF patients and is further increased 60 min after initiation of HD, regardless of the nature of the HD membrane used. PMN activation, increased TNF‐α and IL‐1β levels, or a direct PMN impairment may cause the observed cell rigidity.
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ABSTRACT: Eosinophilic peritonitis following peritoneal dialysis catheter insertion is an infrequent but important complication. While allergic reaction to catheter material has been noted to be a culprit, air infusion into the abdominal cavity has also been highlighted to be a cause of this complication. In this article, we report two patients with end-stage renal disease where air entrapment in the peritoneal cavity during a peritoneal dialysis catheter insertion resulted in eosinophilic peritonitis. The complication resolved with the reabsorption of entrapped intraperitoneal air and treatment with ketotifen. Peritonitis observed in the postoperative period during the peritoneoscopic insertion of a peritoneal dialysis catheter could be the result of air entrapment. Such patients might not require antibiotic therapy or catheter removal. Reabsorption of entrapped air and treatment with ketotifen might be all that is required.
Seminars in Dialysis 21(2):180-2. · 2.27 Impact Factor
