A combined crystalloid and colloid PD solution as a glucose-sparing strategy for volume control in high-transport Apd Patients: A prospective multicenter study

◆ Background: Evidence is accumulating that the continuous exposure to high glucose concentrations during peritoneal dialysis (PD) is an important cause of ultrafiltration (UF) failure. The cornerstone of prevention and treatment of UF failure is reduction of glucose exposure, which will also alleviate the systemic impact of significant free glucose absorption. The challenge for the future is to discover new therapeutic strategies to enhance fluid and sodium removal while diminishing glucose load and exposure using combinations of available osmotic agents. ◆ Objectives: To investigate in patients on automated PD (APD) with a fast transport pattern whether there is a glucose-sparing advantage to replacing 7.5% icodextrin (ICO) during the long dwell with a mixed crystalloid and colloid PD fluid (bimodal UF) in an attempt to promote daytime UF and sodium removal while diminishing the glucose strength of the dialysate at night. ◆ Design: A 2 parallel arm, 4 month, prospective nonrandomized study. ◆ Setting: PD units or university hospitals in 4 French and Belgian districts. ◆ Results: During the 4-month intervention period, net UF and peritoneal sodium removal during the long dwell when treated by bimodal UF was about 2-fold higher than baseline (with ICO). The estimated percent change (95% confidence interval) from baseline in net daytime UF for the bimodal solution was 150% (106% - 193%), versus 18% (∼7% - 43%) for ICO (p < 0.001). The estimated percent change from baseline in peritoneal sodium removal for the bimodal solution was 147% (112% - 183%), versus 23% (∼2% - 48%) for ICO (p < 0.001). The estimated percent change from baseline in UF efficiency (24-hour net UF divided by the amount of glucose absorbed) was significantly higher (p < 0.001) when using the bimodal solution was 71%, versus ∼5% for ICO. ◆ Conclusion: Prescription of bimodal UF during the day in APD patients offers the opportunity to optimize the long dwell exchange in a complete 24-hour APD cycle. The current study demonstrated that a bimodal solution based on the mixing of glucose (2.6%) and icodextrin (6.8%) achieved the double target of significantly improving UF and peritoneal sodium removal by exploring a new concept of glucose-sparing PD therapy. Copyright © 2009 International Society for Peritoneal Dialysis.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

NOVEL PREDICTORS OF PERITONITIS-RELATED OUTCOMES IN THE BRAZPD COHORT

Introduction: Peritonitis remains the main cause of peritoneal dialysis (PD) technique failure worldwide, despite significant reductions in infection rates observed over the past decades. Several studies have described risk factors for peritonitis, technique failure and mortality. However, there are scarce data regarding predictors of complications during and after a peritonitis episode. The aim of our study was to analyze predictors of peritonitis-related outcome in the Brazilian Peritoneal Dialysis study (BRAZPD) cohort.Methods: All adult incident patients recruited in the BRAZPD Study between December 2004 and October 2007, who remained at least 90 days on PD and presented their first peritonitis episode (n = 474 patients) were included in the study. The endpoints analyzed were non-resolution, death due to a peritonitis episode and long-term technique survival after a peritonitis episode.Results: In the multivariable regression, non-resolution was independently associated with older age (odds ratio (OR) 1.02; p < 0.01), collagenosis as the primary renal disease (OR 4.6; p < 0.05) and Pseudomonas spp as etiological agent (OR 2.9; p < 0.05). Patients who were transferred from APD to CAPD during peritonitis therapy presented a higher risk of non-response (OR 2.5; p < 0.05). The only factor associated with death during a peritonitis episode was older age (OR 1.04; p < 0.05). Exposure to vancomycin and male gender were the independent predictors of long-term technique failure (OR 2.2; p < 0.01).Conclusion: Apart from confirming previous observations of the negative impact of older age and Pseudomonas spp peritonitis on outcomes, we observed that collagenosis may negatively impact response to treatment and exposure to vancomycin may possibly reduce long-term technique survival. It is important to emphasize that the association of vancomycin with technique failure does not prove causality. These findings shed light on new factors predicting outcome when peritonitis is diagnosed

Changes in peritoneal membrane with different peritoneal dialysis solutions: Is there a difference?

Background/Purpose: The peritoneal membrane of long-term peritoneal dialysis (PD) patients is characterized by morphological and microvascular changes. It is said that lactate-based peritoneal dialysate is implicated in the development of these changes. The aim of this study is to compare the effects of long-term exposure to glucose-based, lactate-buffered (Dianeal), and biocompatible bicarbonate/lactate-buffered, low glucose degradation product (Physioneal) peritoneal solutions on the peritoneal membrane. Methods: Thirty-nine incident PD patients were randomized into two groups: 19 patients with Dianeal dialysate (Group A) and 20 with biocompatible Physioneal dialysate (Group B). All patients used automated PD for a median of 31 months in Group A and 32 months in Group B. Three biopsies at one occasion only were taken from the peritoneal membrane at the end of the study. All samples were collected and fixed in accordance with a standardized protocol, and a histopathologist blinded to the clinical status and PD solutions allocated to the patients carried out the analysis. Results: The commonest change observed was peritoneal fibrosis, seen in 35 out of 39 cases (89.7%); it was moderate to severe in 28 cases (71.8%) and mild in 11 (28.2%) cases. This was followed by loss of mesothelial cells (22 cases, 56.4%), elastosis (20 cases, 51.3%), increased blood vessels (15 cases, 38.5%), thick-walled blood vessels (10 cases, 25.6%), and finally chronic inflammation and mesothelial cell hyperplasia (7 cases, 17.9%, and 6 cases, 15.4%, respectively). Of the patients with blood vessel abnormalities, 22 (88.0%) exhibited significant fibrosis and only three (12.0%) did not. Of those without blood vessel changes, only six (42.9%) patients exhibited similar degree of fibrosis (p < 0.01). The prevalence of vascular changes, moderate to severe fibrosis, as well as mesothelial cell abnormalities increased as the duration of PD increased. The prevalence of fibrosis, mesothelial cell loss, and vascular abnormalities increased significantly with diabetes mellitus (p < 0.001). Conclusion: There was no difference in the effects of long-term exposure to glucose-based, lactate-buffered, and biocompatible bicarbonate/lactate-buffered, low glucose degradation product peritoneal solutions on the peritoneal membrane. Risk factors other than PD dialysate composition need to be considered when assessing peritoneal membrane adequacy. The factors that were proved to be significant in our study are duration of end-stage renal disease, diabetes mellitus, and time on PD. 背景 / 目的: 在接受長期腹膜透析 (PD) 的病人間，腹膜會出現若干的形態學與微血管變化，這些變化被認為與採用乳酸鹽腹膜透析液有關。本研究旨在比較兩種透析液的長期暴露—乳酸鹽緩衝之 Dianeal®、與生物相容之 Physioneal® 對病人腹膜的影響。 方法: 共 39 位剛開始接受 PD 的病人被分為兩組：19 人接受 Dianeal 透析液 (A 組)、20 人接受生物相容之 Physioneal 透析液 (B 組)，所有病人接受的均為自動化 PD (APD)。研究結束時，我們對病人腹膜進行了活組織檢驗。 結果: 在 A 組及 B 組之間，間皮細胞消失分別發生於 52.6% 及 60.0% 的病人，間皮細胞增生則分別發生於 21.1% 及 15.0% 的病人 (p > 0.05)；嚴重間質纖維化分別發生於 42.1% 及 45.0% 的病人，中度間質纖維化則分別發生於 31.6% 及 25.0% 的病人 (p > 0.05)。在 A 組及 B 組的病人之間，彈性組織變性 (elastosis) 達到 “3+” 的比率分別為 15.8% 及 20.0%，達到 “2+” 的比率分別為 15.8% 及 15.0% (p > 0.05)；異常微血管增加則分別出現於 42.1% 及 35.0% 的病人 (p > 0.05)。在糖尿病患者之間、及接受 PD 較久的病人之間，腹膜病理性變化的比率均有所增加 (p < 0.001)。 結論: 長期採用以上兩種腹膜透析液於 PD 病人中，並未導致不同的腹膜變化。然而，以下因素則可能導致不同的腹膜變化：末期腎病、糖尿病、及 PD 的持續時間

Type of dialysis access at first dialysis session accordingly with different studied subgroups.

<p>Abbreviations: ER+P, early referral and planned patients; ER+NP, early referral and non-planned patients; LR+P, late referral and planned patients; LR+NP, late referral and non-planned patients. PD, peritoneal dialysis; HD, hemodialysis; AVF, arterio-venous fistula. Figure represents a diagram of bars showing the different types of accesses at first dialysis session. Accesses were as follows for the total population: 34.5% AVF, 8% peritoneal catheter, 8.5% temporal hemodialysis catheter and 49% permanent HD catheter. For ER+P: 77% AVF, 21% peritoneal catheter, no temporal hemodialysis catheter and 2% permanent HD catheter. For ER+NP: 0.8% AVF, 2.6% peritoneal catheter, 9% temporal hemodialysis catheter and 88% permanent HD catheter. For LR+P: 89% AVF, 8% peritoneal catheter, no temporal hemodialysis catheter and 3% permanent HD catheter. For LR+NP: 0.4% AVF, 1% peritoneal catheter, 18% temporal hemodialysis catheter and 80% a permanent HD catheter.</p

Multivariate logistic regression for planned versus non-planned dialysis start.

<p>Pseudo r2 = 0.26.</p

Reasons for non-planned start and need of urgent dialysis start.

<p>Reasons for non-planned start and need of urgent dialysis start.</p

Peritoneal dialysis (PD) incidence (%) according with different studied subgroups.

<p>Maximum PD incidence was observed in the optimal care treated patients group being 22%. PD ranged 18% in the planned dialysis start, 16% in the early referred patients, 12% at modality information provision, 6% in the non-planned dialysis start, 5% in the late referral and no PD was observed if never previously informed. PD at the first dialysis session occurred in 8% and as first chronic RRT in 11% of the total studied population.</p

Clinical characteristics according to initial RRT modality.

<p>Clinical characteristics according to initial RRT modality.</p

Clinical characteristics according to planning of dialysis start.

<p>Clinical characteristics according to planning of dialysis start.</p