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

The use of interactive video has been recognized as a means of delivering medical support to isolated areas since the 1950s. The Department of Defense recognized early the capacity of telemedicine to deliver medical care and support to front-line military personnel. In 1989, the Texas Telemedicine Project received grants and support from the then American Telephone and Telegraph Company (now AT&T) and the Meadows Foundation of Dallas, Texas, to establish and evaluate telemedicine delivery in central Texas. That project had 6 connected telemedicine sites: 3 in Austin, Texas, and 3 in Giddings, Texas (a small community 55 miles to the southeast of Austin). The sites in Giddings included a chronic outpatient dialysis facility, an inpatient psychiatric hospital, and the emergency department at Giddings Hospital. Patient contact began in April 1991 and continued through March 1993. During that period, data on the 1500 patient contacts made were recorded. After termination of the Texas Telemedicine Project, AT&T continued to provide the transmission lines, and between 1993 and 1996, another 12,000 patient contacts were made. Approximately 80% were dialysis evaluations and 20% were non-dialysis primary care contacts. The original cost of materials and equipment in the Texas Telemedicine Project exceeded $50,000 per site. Today, a secure Internet connection with full-motion video and wireless data transfer to almost any location in the world is achievable with an iPad. Multiple inexpensive applications with connections for electrocardiogram, otoscope, and stethoscope, among others, make this technology extremely inexpensive and user-friendly. The revolution now is rapidly moving forward, with Medicare reimbursing telemedicine contacts in medically underserved areas. Multiple bills are before Congress to expand Medicare and therefore private insurance payment for this service.

The aim of the present study was to assess the influence of peritoneal permeability expressed as the dialysate-to-plasma ratio of creatinine (D/P Cr) on total and cardiovascular (CV) mortality in a population of peritoneal dialysis (PD) patients during a 6-year observation period. The study recruited 55 patients (mean age: 53 years) treated with PD for a median of 24 months. Hematology parameters and serum albumin were determined using routine methods. Tumor necrosis factor alpha (TNF-alpha) and transforming growth factor beta (TGF-beta1) were determined by high-sensitivity ELISA. Peritoneal transport characteristics were identified using D/P Cr reference values after a peritoneal equilibration test. During the 6-year observation period, 22 patients (40%) died, mostly from CV complications (77% of deaths). In multiple Cox regression, D/P Cr and dialysate volume at PD initiation predicted total [hazard ratio (HR): 1.57; p = 0.02; and HR: 1.20; p = 0.04 respectively] and CV mortality (HR: 1.65; p = 0.02; and HR: 1.23; p = 0.05 respectively) independent of age, dialysis therapy duration, serum albumin concentration, dialysis adequacy measures, TGF-beta1, and TNF-alpha. Additionally, TNF-alpha was independently associated with all-cause and CV mortality, and albumin, with all-cause mortality. Baseline D/P Cr was a strong independent marker of survival in PD patients. Baseline D/P Cr and dialysate volume were independent risk factors for total and CV mortality in the PD population and could be significant for assessing CV risk in this population.

Peritonitis remains a leading complication of peritoneal dialysis (PD). About 18% of the infection-related mortality in PD patients is a result of peritonitis. We present a case of peritonitis in a patient on automated PD in whom the infection was not related to a break in PD technique, but to an unusual cause: retrograde transmission of a gonococcal organism.

In the United States, interest has recently been renewed in the more urgent initiation of peritoneal dialysis (PD) to avoid temporary vascular access catheters in appropriate patients presenting late in the course of their kidney disease. Urgent-start PD programs have been established across the country, requiring new infrastructure and processes of care. Less is known about early technique success after urgent initiation of PD. In this report, we describe 90-day technique success and causes of hospitalization in 81 patients initiating PD in our urgent-start pathway.

Approximately 10% - 20% of adult kidney transplant recipients and as many as 40% of pediatric recipients receive peritoneal dialysis (PD) before kidney transplantation. An important aspect of perioperative kidney transplant care is management of the PD catheter. Peritoneal dialysis can be performed immediately after transplantation for delayed graft function (DGF), which can occur with as many as 20% of deceased-donor kidney grafts, especially when expanded criteria or organs from donation after cardiac death are used. However, leaving the PD catheter in place has been associated with an increased risk for infections such as peritonitis and exit-site infection, even when the catheter is not used. Although no consensus has been reached about the management of PD catheters after kidney transplantation, transplant centers should have a low threshold for PD catheter removal at the time of surgery, especially in recipients with a low risk for DGF. In individuals with high risk for DGF the PD catheter can be left in place, but it must be removed in a timely manner once it is no longer needed.

Qualitative assessments in long-term patients and in those with encapsulating peritoneal sclerosis (EPS) have shown that impaired osmotic conductance is likely a factor contributing to the presence of ultrafiltration failure in those individuals. In the present study, we investigated the value of osmotic conductance, its components LpA and the reflection coefficient sigma, and free water transport (FWT) in 12 patients with EPS, in 21 patients with long-term ultrafiltration failure, and in 26 time-restricted control subjects with normal ultrafiltration. A decrease in all parameters was observed during a period of 4 years in patients with EPS and ultrafiltration failure, with FWT showing the largest difference between all three groups; however, the receiver operating curves showed that only FWT appeared to be a significant predictor of EPS. Because its measurement is simple, FWT should be included in the regular assessment of peritoneal function.

Patients with end-stage renal disease treated with peritoneal dialysis (PD) are often put on standard one size fits all" regimens, despite having varying degrees of residual renal function (RRF). The present study reports our experience with initiation of PD using 2 icodextrin exchanges daily in patients with RRF corresponding to a weekly Kt/Vurea of at least 1.0. Peritoneal and RRF Kt/Vurea were tracked closely, and total Kt/Vurea was maintained between 1.7 and 2.0. One patient developed a rash and was changed to 3 dextrose exchanges daily. All patients were satisfied with their treatment regimen, and no other adverse events or symptoms were reported.

Clinicians caring for patients on peritoneal dialysis (PD) have relied on a variety of laboratory measures to assess the health of patients and their response to treatment. Traditionally, serum albumin has been an indicator of nutrition status and has therefore been included in monthly blood testing in most centers. The development of hypoalbuminemia in dialysis patients has been associated with increased mortality and often leads to interventions such as trials of nutritional supplements. In PD, hypoalbuminemia combined with ongoing losses of protein into effluent raise particular concerns with clinicians. Serum albumin may be affected by a variety of non-nutrition factors such as inflammation, volume status, and comorbidities. Albumin synthesis in the liver exceeds, in most cases, albumin losses in urine or effluent. Interpreting the medical implications of declining serum albumin in PD patients can therefore be a challenge. This paper reviews protein balance in PD. The nutritional and non-nutritional factors affecting serum albumin are discussed, with specific emphasis on how membrane physiology contributes to dialysate protein losses. A general clinical approach to the PD patient developing hypoalbuminemia is discussed.

Data regarding the outcomes of peritoneal dialysis (PD) patients undergoing nephrectomy are limited. In the 20-year retrospective study reported here, we included patients who underwent nephrectomy and then subsequently started PD within 1 year (group A) and those who underwent nephrectomy while already on PD (group B). We examined mechanical complications including incisional hernia, peritoneal leak, and wound infection or dehiscence. Among biochemical outcomes (group B only), we analyzed serum creatinine, albumin, potassium, and phosphate for 1 year pre- and post-nephrectomy. Among the 8 patients identified (4 in group A, 4 in group B), 7 underwent unilateral nephrectomy, and 1, bilateral nephrectomy. Surgery was laparoscopic in 1 patient and open in 7 patients. The approach was transperitoneal in 5 patients, and retroperitoneal in 3 patients. Incisional hernia occurred in 4 patients (2 in each group), and retroperitoneal leak was seen in 1 patient in group B after 2 months. No wound dehiscence or other complications occurred. In group B, 2 patients required hybrid therapy in the form of once-weekly hemodialysis with continuous ambulatory PD. Among the biochemical complications, we noted that serum creatinine increased (as expected), and serum albumin significantly declined and remained lower post-nephrectomy. Our data show that, post-nephrectomy, PD patients have a high incidence of incisional hernia. They also experience a significant decline in serum albumin and a substantial loss in residual kidney function potentially requiring intensified dialysis. The retroperitoneal approach may on occasion predispose to retroperitoneal leak of dialysate.

Because of a higher (but improving) incidence of technique failure, peritoneal dialysis (PD) is not thought to equal hemodialysis (HD) for long-term use. Other than death and transplantation, the reasons that patients leave PD include peritonitis, catheter problems, patient burnout, and (in long-duration patients) the development of encapsulating peritoneal sclerosis or ultrafiltration failure. Here, we report 2 patients who have been on continuous ambulatory PD continuously for more than 12 years, maintaining good ultrafiltration and clearances. In the case reports, we suggest potential reasons for the long duration of therapy in these women. We conclude that, in some patients on continuous ambulatory PD who sparingly use very hyperosmolar dextrose solutions and who are able to avoid frequent episodes of peritonitis, long-term PD is possible and may not require transition to HD.