Advances in peritoneal dialysis. Conference on Peritoneal Dialysis最新文献

Free water transport (FWT) during peritoneal dialysis (PD) can easily be measured by Na⁺ kinetics. In long-term PD, FWT might reflect peritoneal fibrosis, but morphologic or functional relationships have not been investigated. Nonconventional dialysis solutions might be associated with better preservation of peritoneal tissues and function. We developed a long-term peritoneal exposure model in rats with impaired kidney function and investigated peritoneal morphology and function in that model after exposure to conventional and nonconventional solutions.Two studies were reanalyzed. Transport was assessed using a standard peritoneal permeability analysis adapted for the rat. Omental tissue was stained with picro-sirius red (PSR) for uniform quantification of fibrosis. A semiquantitative fibrosis score was also calculated.Rats (n = 9) exposed to a conventional solution for 16 weeks were compared with rats (n = 9) exposed to other solutions. Peritoneal transport parameters were similar, but the degree of fibrosis tended to be more severe in the conventional-solution group. Compared with the situation in humans, the contribution of FWT to ultrafiltration in rats was larger than that of small-pore fluid transport. No correlation between the percentage PSR positivity and FWT was observed. A marked difference in PSR positivity was found between the two studies.The long-term exposure model is not suitable for the study of relationships between FWT and peritoneal fibrosis. Quantitative assessment of the fibrosis is difficult.

Upon peritoneal dialysis (PD) discontinuation in frail patients, we have re-embedded the catheter and left it subcutaneously buried. However, we have not evaluated the long-term prognosis of those patients after the procedure or the complications associated with buried catheters. We therefore aimed to clarify the long-term prognosis of patients with a re-embedded catheter and to identify any associated complications.The outcomes of 10 patients having a catheter that was re-embedded between February 2010 and May 2016 were assessed by interviewing the patients or their families (when possible), and by reviewing medical records.Catheter re-embedding to reduce the surgical burden was elected by 7 patients, and 3 patients underwent re-embedding because they wanted to resume PD in the future. By the time of the interviews, 6 patients had already died of causes that were unrelated either to the buried catheter or infection. No abnormality was found in any buried catheter. A re-embedded catheter was later externalized to resume PD in 1 of the 4 patients who survived.Catheter re-embedding is safe and allows for PD resumption at the terminal stage of dialysis.

Hernias and peritoneal dialysis (PD) catheter leaks are frequent complications in patients on PD. Transplant recipients have multiple risk factors for delayed wound healing, such as use of corticosteroids and sirolimus, and the presence of uremia and diabetes mellitus. We report a rare occurrence of incisional hernia attributable to internal wound dehiscence after PD catheter placement in a patient on sirolimus.A 34-year-old Latino American man was started on PD training 4 weeks after placement of a PD catheter. Soon after completing training, he developed a large soft bulge close to the PD catheter, with expansile cough impulse suggestive of an incisional hernia filled with peritoneal dialysate. The size of the bulge would decrease after the dialysate was drained. No external leak of dialysate was evident along the exit site.Because of the size of the hernia and the history of it filling soon after dialysis exchange, the feeling was that wound dehiscence had occurred from the peritoneal side, resulting in a large incisional hernia. Because of the large size of the hernia within few weeks of starting PD, sirolimus was suspected to have induced poor wound healing, contributing to formation of the hernia.Sirolimus was stopped, and the patient underwent PD catheter removal and repair of the hernia. A new PD catheter was placed on the opposite side of the abdomen 10 days later. After another 6 weeks, the patient was started on PD. He has been doing well for the 15 months since then, with no recurrence of the hernia. Because he still had residual renal function, he continued to receive low-dose prednisone and mycophenolate sodium. At 10 months after PD start, he stopped the mycophenolate sodium on his own, and we did not resume it. He is still on low-dose prednisone.In end-stage renal disease resulting from failing renal transplantation or from calcineurin inhibitor nephropathy in solid-organ transplantation, sirolimus is a risk factor for wound dehiscence, development of incisional hernia, and peritoneal dialysate leak.Practical tips: Sirolimus should be stopped several days before PD catheter placement. Sirolimus should also be stopped if a PD catheter leak is detected or if incisional hernia develops soon after initiation of PD. Sirolimus should be held till surgical repair of the hernia and removal and replacement of the catheter.

Patients with end-stage renal failure are believed to have an increase of oxidative stress. However, any variation in oxidative stress between patients receiving hemodialysis (HD) and those receiving peritoneal dialysis (PD) are still unclear. In the present study, we investigated variation in oxidative stress in 54 HD and 23 PD patients during their initial dialysis period.We measured serum pentosidine and indoxylsulfuric acid as markers of oxidative stress every 6 months from the start of the dialysis therapy to 30 months of treatment. Serum pentosidine was significantly lower in the PD patients than in the HD patients. Serum indoxylsulfuric acid was also significantly lower in the PD group compared with the HD group at 6, 12, and 18 months. Compared with the HD patients, the PD patients maintained significantly higher urine volumes (a marker of residual renal function) throughout the study, except at 24 months.Our findings demonstrate that, compared with HD patients, PD patients experience lower levels of oxidative stress because of higher preserved residual renal function during the initial dialysis period.

Hyper- and hypophosphatemia are recognized risk factors for all-cause mortality in peritoneal dialysis (PD) patients. Recent changes have now focused PD solute clearance targets on urea clearance, rather than on larger solutes, including phosphate. We therefore studied peritoneal phosphate clearance in a cohort of PD patients to determine which factors were clinically relevant.We reviewed results from 451 adult PD patients who were attending for their first assessment of peritoneal membrane function [31.2% treated by continuous ambulatory PD (CAPD); 24.2.%, by automated PD (APD); and 44.6% by APD with a daytime exchange]. Demographics, PD adequacy parameters, peritoneal phosphate clearance, and transport status were reviewed.Of the study patients, 119 (26.4%) were hyperphosphatemic, and 59 (30.1%) were hypophosphatemic; 22.2% were fast transporters. Total daily peritoneal phosphate losses were greater for the hyperphosphatemic than for the hypophosphatemic patients [15 mg/ dL (range: 10.5-18.6 mg/dL) vs. 25.7 mg/dL (range: 15.5-29.8 mg/dL), p < 0.01], although peritoneal phosphate clearance was less [2.7 mL/min/1.73 m² (range: 1.6-4.1 mL/min/1.73 m²) vs. 4.2 mL/ min/1.73 m² (range: 2.1-4.1 mL/min/1.73 m²), p < 0.001]. Peritoneal phosphate clearance was greater for faster compared with slower transporters [3.5 mL/ min/1.73 m² (range: 2.5-4.5 mL/min/1.73 m²) vs. 1.6 mL/min/1.73 m² (range: 1.1-2.2 mL/min/1.73 m²), p < 0.05] and for patients treated either with APD plus a daytime exchange or with CAPD compared with APD alone [3.44 mL/min/1.73 m² (range: 2.3-5.0 mL/ min/1.73 m²) vs. 2.9 mL/min/1.73 m² (range: 1.5- 4.4 mL/min/1.73 m²) vs. 1.6 mL/min/1.73 m² (range: 1.1-2.4 mL/min/1.73 m², p < 0.001)]. On multivariate analysis, increased peritoneal clearance was associated with faster peritoneal transport status, younger age, lower serum albumin, and lower serum phosphate.Peritoneal phosphate clearance depends not only PD modality, but also patient factors, including peritoneal transport status and variables associated with inflammation.

Endogenous peritonitis resulting from inflammation or perforation of an abdominal viscus-a result, for example, of diverticulitis, cholecystitis, or acute appendicitis-can be a complication in patients undergoing peritoneal dialysis (PD), with significant morbidity and a high incidence of catheter loss.Here, we describe an end-stage renal disease patient on PD who presented with acute abdominal pain and who was diagnosed with uncomplicated PD peritonitis. His clinical course was complicated by development of eosinophilic peritonitis because of an allergy to vancomycin. Subsequently, when he failed to show clinical improvement, abdominal and pelvic imaging revealed severe appendicitis, which necessitated emergent surgical intervention.

Peritoneal dialysis (PD) and hemodialysis (HD) combination therapy is considered for the improvement of ultrafiltration failure and uremic symptoms in PD patients with loss of residual renal function (RRF). However, a rapid decline in RRF is one of the critical drawbacks to such therapy. In contrast, we started patients on combination therapy as a proactive option at the initiation of dialysis.In patients on HD (n = 52), PD (n = 21), and combination dialysis (n = 13), we studied changes in RRF, blood parameters, and peritoneal permeability for 30 months. Residual renal function was better preserved in patients who received PD and HD combination therapy from the start of the dialysis therapy than in patients who received HD alone, and serum albumin was better preserved in the combination-therapy patients than in the patients who received PD alone. No significant differences in peritoneal permeability were observed between the patients on PD and those on combination therapy. Blood parameters were not significantly different between the three groups.Because our proactive combination therapy option has beneficial effects compared with HD or PD therapy alone, combination therapy should be considered a new modality of renal replacement therapy.

Complications of peritoneal dialysis (PD) create a significant burden for patients and providers. Some complications, such as infections and leaks, are preventable or easily treatable; however, potential fatal complications, such as encapsulating peritoneal sclerosis (EPS), cost patients their lives. Here, we present the case of a PD patient who might have had early, subtle, but ominous symptoms and signs of EPS, diagnosed in its early stages and promptly managed.A 57-year-old man who had been receiving PD for 6 years began having recurrent episodes of abdominal pain, blood-tinged effluent, and peritonitis. Even after successful treatment of his peritonitis episode, his dialysate effluent would be intermittently hazy or pinkish. When he presented with similar complaints for the third time, he was diagnosed with EPS after laparoscopy for further evaluation during his hospitalization.Encapsulating peritoneal sclerosis is a rare complication of PD. The advanced stages of EPS with "EPS syndrome" portend a grave prognosis because of small-bowel obstruction, malnutrition, infection, and death. Early recognition and timely intervention can be a strategy to potentially prevent the progression of EPS.

Peritoneal dialysis (PD) is an umbrella term that encompasses a variety of techniques such as continuous ambulatory PD, automated PD, tidal PD, and intermittent PD, among others. The various techniques exist to tailor the PD prescription to meet the goals of individual patients. Various clinical and nonclinical factors can change over time, requiring a change to the PD prescription. This article uses a practical case study to highlight the intricacies of the calculations behind PD prescription to achieve clearance goals. The objective is to demonstrate that all modalities of PD should be considered in the spectrum of clinical tools for achieving adequate dialysis.