Incremental peritoneal dialysis: a 10 year single-centre experience

INTRODUCTION: Incremental dialysis consists in prescribing a dialysis dose aimed towards maintaining total solute clearance (renal + dialysis) near the targets set by guidelines. Incremental peritoneal dialysis (incrPD) is defined as one or two dwell-times per day on CAPD, whereas standard peritoneal dialysis (stPD) consists in three-four dwell-times per day. PATIENTS AND METHODS: Single-centre cohort study. Enrollement period: January 2002-December 2007; end of follow up (FU): December 2012. INCLUSION CRITERIA: incident patients with FU ≥6 months, initial residual renal function (RRF) 3-10 ml/min/1.73 sqm BSA, renal indication for PD. RESULTS: Median incrPD duration was 17 months (I-III Q: 10; 30). There were no statistically significant differences between 29 patients on incrPD and 76 on stPD regarding: clinical, demographic and anthropometric characteristics at the beginning of treatment, adequacy indices, peritonitis-free survival (peritonitis incidence: 1/135 months-patients in incrPD vs. 1/52 months-patients in stPD) and patient survival. During the first 6 months, RRF remained stable in incrPD (6.20 ± 2.02 vs. 6.08 ± 1.47 ml/min/1.73 sqm BSA; p = 0.792) whereas it decreased in stPD (4.48 ± 2.12 vs. 5.61 ± 1.49; p < 0.001). Patient survival was affected negatively by ischemic cardiopathy (HR: 4.269; p < 0.001), peripheral and cerebral vascular disease (H2.842; p = 0.006) and cirrhosis (2.982; p = 0.032) and positively by urine output (0.392; p = 0.034). Hospitalization rates were significantly lower in incrPD (p = 0.021). Eight of 29 incrPD patients were transplanted before reaching full dose treatment. CONCLUSIONS: IncrPD is a safe modality to start PD; compared to stPD, it shows similar survival rates, significantly less hospitalization, a trend towards lower peritonitis incidence and slower reduction of renal function

Factors influencing the decision to start renal replacement therapy: results of a survey among European nephrologists

Background: Little is known about the criteria nephrologists use in the decision of when to start renal replacement therapy (RRT) in early referred adult patients. We evaluated opinions of European nephrologists on the decision for when to start RRT. Study Design: European web-based survey. Predictors: Patient presentations described as uncomplicated patients, patients with unfavorable clinical and unfavorable social conditions, or patients with specific clinical, social, and logistical factors. Setting & Participants: Nephrologists from 11 European countries. Outcomes & Measurements: We studied opinions of European nephrologists about the influence of clinical, social, and logistical factors on decision making regarding when to start RRT, reflecting practices in place in 2009. Questions included target levels of kidney function at the start of RRT and factors accelerating or postponing RRT initiation. Using linear regression, we studied determinants of target estimated glomerular filtration rate (eGFR) at the start of RRT. Results: We received 433 completed surveys. The median target eGFR selected to start RRT in uncomplicated patients was 10.0 (25th-75th percentile, 8.0-10.0) mL/min/1.73 m(2). Level of excretory kidney function was considered the most important factor in decision making regarding uncomplicated patients (selected by 54% of respondents); in patients with unfavorable clinical versus social conditions, this factor was selected by 24% versus 32%, respectively. Acute clinical factors such as life-threatening hyperkalemia refractory to medical therapy (100%) and uremic pericarditis (98%) elicited a preference for an immediate start, whereas patient preference (69%) and vascular dementia (66%) postponed the start. Higher target eGFRs were reported by respondents from high-versus low-RRT-incidence countries (10.4 [95% CI, 9.9-10.9] vs 9.1 mL/min/1.73 m(2)) and from for-profit versus not-for-profit centers (10.1 [95% CI, 9.5-10.7] vs 9.5 mL/min/1.73 m(2)). Limitations: We were unable to calculate the exact response rate and examined opinions rather than practice for 433 nephrologists. Conclusions: Only for uncomplicated patients did half the nephrologists consider excretory kidney function as the most important factor. Future studies should assess the weight of each factor affecting decision making. Am J Kidney Dis. 60(6): 940-948. (C) 2012 by the National Kidney Foundation, In

Low-protein diets for chronic kidney disease patients: The Italian experience

open20Nutritional treatment has always represented a major feature of CKD management. Over the decades, the use of nutritional treatment in CKD patients has been marked by several goals. The first of these include the attainment of metabolic and fluid control together with the prevention and correction of signs, symptoms and complications of advanced CKD. The aim of this first stage is the prevention of malnutrition and a delay in the commencement of dialysis. Subsequently, nutritional manipulations have also been applied in association with other therapeutic interventions in an attempt to control several cardiovascular risk factors associated with CKD and to improve the patient's overall outcome. Over time and in reference to multiple aims, the modalities of nutritional treatment have been focused not only on protein intake but also on other nutrients.openBellizzi, Vincenzo; Cupisti, Adamasco; Locatelli, Francesco; Bolasco, Piergiorgio; Brunori, Giuliano; Cancarini, Giovanni; Caria, Stefania; De Nicola, Luca; Di Iorio, Biagio R; Di Micco, Lucia; Fiaccadori, Enrico; Garibotto, Giacomo; Mandreoli, Marcora; Minutolo, Roberto; Oldrizzi, Lamberto; Piccoli, Giorgina B; Quintaliani, Giuseppe; Santoro, Domenico; Torraca, Serena; Viola, Battista FBellizzi, Vincenzo; Cupisti, Adamasco; Locatelli, Francesco; Bolasco, Piergiorgio; Brunori, Giuliano; Cancarini, Giovanni; Caria, Stefania; De Nicola, Luca; Di Iorio, Biagio R; Di Micco, Lucia; Fiaccadori, Enrico; Garibotto, Giacomo; Mandreoli, Marcora; Minutolo, Roberto; Oldrizzi, Lamberto; Piccoli, Giorgina B; Quintaliani, Giuseppe; Santoro, Domenico; Torraca, Serena; Viola, Battista F

Outcomes of pregnancies after kidney transplantation: lessons learned from CKD. A comparison of transplanted, nontransplanted chronic kidney disease patients and low-risk pregnancies: a multicenter nationwide analysis.

BACKGROUND: Kidney transplantation (KT) may restore fertility in CKD. The reasons why materno-foetal outcomes are still inferior to the overall population are only partially known. Comparison with the CKD population may offer some useful insights for management and counselling.Aim of this study was to analyse the outcomes of pregnancy after KT, compared with a large population of non-transplanted CKD patients and with low-risk control pregnancies, observed in Italy the new millennium. METHODS: We selected 121 live-born singletons after KT (Italian study group of kidney in pregnancy, national coverage about 75%), 610 live-born singletons in CKD and 1418 low-risk controls recruited in 2 large Italian Units, in the same period (2000-2014). The following outcomes were considered: maternal and foetal death; malformations; preterm delivery; small for gestational age baby (SGA); need for the neonatal intensive care unit (NICU); doubling of serum creatinine or increase in CKD stage. Data were analysed according to kidney diseases, renal function (staging according to CKD-EPI), hypertension, maternal age, partity, ethnicity. RESULTS: Materno-foetal outcomes are less favourable in CKD and KT as compared with the low-risk population. CKD stage and hypertension are important determinants of results. KT patients with e-GFR >90 have worse outcomes compared with CKD stage 1 patients; the differences level off when only CKD patients affected by glomerulonephritis or systemic diseases ('progressive CKD') are compared with KT. In the multivariate analysis, risk for preterm and early-preterm delivery was linked to CKD stage (2-5 versus 1: RR 3.42 and 3.78) and hypertension (RR 3.68 and 3.16) while no difference was associated with being a KT or a CKD patient. CONCLUSIONS: The materno-foetal outcomes in patients with kidney transplantation are comparable with those of nontransplanted CKD patients with similar levels of kidney function impairment and progressive and/or immunologic kidney diseas

A competing risks model with a time dependent variable: the effects of hypertension onset in the comorbidities history in type 2 diabetes

Atti di convegn

TRANSUDATIVE PLEURAL EFFUSION DUE TO PLEUROPERITONEAL COMMUNICATION IN PERITONEAL DIALYSIS PATIENTS WITH POLYCISTIC KIDNEY DISEASE

BACKGROUND. Transudative pleural effusion due to pleuroperitoneal communication (PPC) is an uncommon complication of peritoneal dialysis (PD). PPC prevalence ranges from 1.6 to 10% in PD patients. PPC is more frequent on the right side and in females. PD is often not proposed to patients with polycistic kidney disease (PKD-pts) due to either possible complications for increased intra-abdominal pressure or infectious risk due to diverticula. This study tries to analyse the outcome of PD in PKD-pts. METHODS. between July 1979 and May 2017, 1026 patients started PD in our centre: 46 (4.5%) patients had PKD and 980 (95.8%) other nephropathy. RESULTS. Not significant difference was found between PKD-pts and and non-PKD patients (nPKD-pts) for age at PD initiation. Fifteen (1.5%) cases of PPC occurred overall (Female/Male:12/3): 6/45 (13.3%) in PKD-pts and 9/980 (0.9%) in nPKD-pts. In eight patients, the diagnosis of PPC occurred within two months of start of PD, in four patients between three and seven months of PD and in three patients between two and five years before PPC diagnosis (p = NS). In 13 patients, the interval between the placement of the catheter and start of the PD (break-in time) was less than 45 days; in a patient it was about three months and in another of about three years (Median 22 days, QI-QIII: 13-30). Break-in in PKD and nPKD-pts was not significant for the appearance of PPC. Final outcome in 46 PKD-pts: 21 patients had died, 19 received a kidney transplant and 6 shifted to HD. CONCLUSIONS. In our experience, PKD does not appear to be a contraindication for PD. PPC is more frequent in this population, but its prevalence does not preclude PD as a valid replacement therapy

PERITONITE DA MYCOBACTERIUM ABSCESSUS IN CAPD: CASE REPORT.

Introduzione. Anche se rara, l'incidenza di peritonite da micobatteri non tubercolari (NTM) in dialisi peritoneale (DP) è rara, ma sembra in aumento (1). Gli NTM sono ubiquitari in natura, ma solitamente non sono virulenti. Le peritoniti da NTM a rapida crescita (RGNTM, di cui fa parte il MycobacteriumAbscessus) si associano ad elevata resistenza farmacologica, elevata probabilità di perdita del catetere, maggiori complicanze e mortalità. Segni e sintomi sono indistinguibili dalla peritonite batterica o tubercolare e la diagnosi precoce è fondamentale (2). Viene riportato un caso di peritonite da Myc. Abscessus(MyA) in una paziente in DP. Descrizione. Donna 83enne in CAPD da 4 anni per ESRD da nefropatia da IgA. Comorbidità: ipertensione arteriosa, cardiopatia ipertensivo-valvolare, FA, portatrice di PM, diverticolosi. Recente peritonite da Staph. Warneri. 21/9/17, ricovero per addominalgia, febbre (38.5°C), liquido peritoneale (LP) torbido, ipotensione, addome dolente e dolorabile. Leucociti su LP 900/mm3: posta diagnosi di peritonite, inviate colture, iniziata terapia empirica con Cefazolinaed Amikacinaintraperitoneali. 22/9, conta leucocitaria peritoneale >5000/mm3: aggiunta Levofloxacinaper os. 25/9, coltura rivela RGNTM: inizia Amikacinaintraperitoneale e Claritromicinaper os. TC addome: negativa. 29/9, identificato MyA: modificata terapia con Amikacina, Tigeciclina, Cefoxitimae Linezolid. Inviato campione per antibiogramma genotipico. Presente anche diarrea dall’ingresso (colonscopia: colite infettiva), regredita con terapia medica. 05/10, avulsione catetere peritoneale e passaggio ad emodialisi tramite CVC di Tesio. Peggioramento degli indici di funzionalità epatica da sospetta epatotossicità jatrogena: temporanea sospensione degli antibiotici in atto (mantenuta solo Amikacina) con risoluzione del quadro. Reintrodotto quindi Linezolid. 3/11, sostituita Amikacinacon Imipenemper ototossicità. Intercorrente anemizzazionee piastrinopeniaa genesi infettiva-jatrogenacon necessità trasfusionale. Risultati. lla dimissione (13/12/17) paziente in discrete condizioni generali, apiretica, normotesa e asintomatica. Ha proseguito con Imipeneme Linezolidfino al 21/1/18 (indicazione infettivologica). Discussione. Le peritoniti da NTM, se pur rare, sono da porre in diagnosi differenziale nelle peritoniti nei pazienti in DP, soprattutto se non vi è una risposta alla terapia antibiotica in corso. Sono essenziali diagnosi precoce e rapida disponibilità dell’antibiogramma per instaurare precocemente una terapia mirata contro questi germi che, come in questo caso, sono spesso multiresistenti. Rimangono da definire: durata della terapia antibiotica, necessità e tempistica dell’avulsione del catetere peritoneale

MALNUTRITION INFLAMMATION SCORE AND RISK OF HOSPITALISATION AND MORTALITY IN PERITONEAL DIALYSIS PATIENTS.

Background. Protein-energy wasting (PEW) represents the state of metabolic and nutritional alteration due to dietetic and non-dietetic factors. Cumulative evidence suggests that PEW is strongly associated with the increasing risk of morbidity and mortality. The aim of the study was to evaluate the association between nutritional status and number of hospitalization and mortality in Peritoneal Dialysis patients. Methods. Nutritional status was assessed with Malnutrition Inflammation Score (MIS) in two times: the follow-up was minimum 6 months for both evaluations and maximum 1 year for the first one and 8 months for the second one. Both MIS were correlated with number of hospitalization and number of death. Results. A total of 80 patients underwent the assessment of nutritional status: the first evaluation (MIS1) includes 38 patients (mean age 64.9±14.9), the second one (MIS2) includes 67 patients (mean age 65.76±14.5). 29% of patients in MIS1 and 31% in MIS2 had moderate PEW, 18% in MIS1 and 4% in MIS2 had severe PEW. There was a significant correlation between nutritional status and number of hospitalizations only in the second evaluation: higher MIS (worst nutritional status) was related to a major number of hospitalizations (p<0.05) than patients with good nutritional status. Furthermore, higher MIS (worst nutritional status) was related to more number of deaths in both evaluations (p<0.001 and p<0.01). Conclusion. MIS can be used as a screening nutritional test and can predict the risk of short-term mortality and hospitalizations in PD patients