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Pet ownership is common around the world, with pet ownership increasing in many countries. Current guidelines are not supportive of pet ownership for peritoneal dialysis (PD) patients. We examined the association between ownership of cats and dogs and the incidence of peritonitis among PD patients participating in the prospective, observational Peritoneal Dialysis Outcomes and Practice Patterns Study. A total of 3655 PD patients from eight different countries was included, with a median follow-up of 14 months and a total exposure time of 55,475 patient-months. There were 1347 peritonitis episodes with an overall peritonitis rate of 0.29 episodes per patient year. There was no significant increased risk of peritonitis with any type of pet ownership, adjusted hazard ratio (HR) of 1.09 (95% confidence interval (95% CI): 0.96–1.25). However, patients who owned both cats and dogs had an increased risk of peritonitis compared to patients without pets, HR = 1.45 (95% CI: 1.14–1.86). These results suggest that there is no increased risk of peritonitis with pet ownership except for those with both cats and dogs. This information should not prevent PD patients from owning pets but may be helpful for PD patients and their care team to direct training to minimise the risk of peritonitis.

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

It is unclear if the pharmacokinetics of vancomycin are the same during automated peritoneal dialysis (APD), where cycler exchanges may affect the systemic, peritoneal, and urinary disposition of drug. We conducted a prospective pharmacokinetic study evaluating the pharmacokinetics of vancomycin in plasma, dialysis fluid, and urine in peritonitis-negative patients on APD. Patients underwent four drug-free exchanges with 1.5% or 2.5% dextrose following the initial dwell period. Plasma, dialysis fluid, and urine was collected over the course of 7 days for pharmacokinetic analysis. Four patients completed the study with no adverse events. Following a median (range) dwell of 14.6 (14.2-17.6 h), the mean (±SD) observed maximum plasma concentration was 28.7 ± 4.9 mg/L with a mean bioavailability of 98.5 ± 1.4% prior to starting the cycler. The overall mean total plasma clearance estimated from study start to completion was 7.6 ± 1.2 ml/min. Mean total clearance during the dialytic exchange was 13.6 ± 4.9 ml/min. In patients with residual renal function, the mean vancomycin renal clearance was 3.1 ± 1.5 ml/min, representing 21.4%-58.9% of the overall total plasma clearance during the study period. Despite the small sample size, this pilot study suggests that the dwell time has important implications for systemic vancomycin exposure, time to therapeutic plasma concentration, and dosing. Dose is driven by dwell time, whereas the cycler determines the dosing interval. Rapid exchanges from APD will determine the frequency of dosing rather than the adequacy of absorption when vancomycin is given in the peritoneum.

Background The effects of training practices on outcomes of patients receiving peritoneal dialysis (PD) are poorly understood and there is a lack of evidence informing best training practices. This prospective cohort study aims to describe and compare international PD training practices and their association with peritonitis. Methods Adult patients on PD Results A total of 1376 PD patients from 120 facilities across seven countries were included. Training was most commonly performed at the facility (81%) by facility-affiliated nurses (87%) in a 1:1 setting (79%). In the UK, being trained by both facility and third-party nurses was associated with a reduced peritonitis risk [adjusted HR 0.31 (95% confidence interval 0.15–0.62) versus facility nurses only]. However, this training practice was utilized in only 5 of 14 UK facilities. No other training characteristics were convincingly associated with peritonitis risk. Conclusions There was no evidence to support that peritonitis risk was associated with when, where, how or how long PD patients are trained.

Peritoneal dialysis (PD)-related peritonitis carries high morbidity for PD patients. Understanding the characteristics and risk factors for peritonitis can guide regional development of prevention strategies. We describe peritonitis rates and the associations of selected facility practices with peritonitis risk among countries participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS).Observational prospective cohort study.7,051 adult PD patients in 209 facilities across 7 countries (Australia, New Zealand, Canada, Japan, Thailand, United Kingdom, United States).Facility characteristics (census count, facility age, nurse to patient ratio) and selected facility practices (use of automated PD, use of icodextrin or biocompatible PD solutions, antibiotic prophylaxis strategies, duration of PD training).Peritonitis rate (by country, overall and variation across facilities), microbiology patterns.Poisson rate estimation, proportional rate models adjusted for selected patient case-mix variables.2,272 peritonitis episodes were identified in 7,051 patients (crude rate, 0.28 episodes/patient-year). Facility peritonitis rates were variable within each country and exceeded 0.50/patient-year in 10% of facilities. Overall peritonitis rates, in episodes per patient-year, were 0.40 (95% CI, 0.36-0.46) in Thailand, 0.38 (95% CI, 0.32-0.46) in the United Kingdom, 0.35 (95% CI, 0.30-0.40) in Australia/New Zealand, 0.29 (95% CI, 0.26-0.32) in Canada, 0.27 (95% CI, 0.25-0.30) in Japan, and 0.26 (95% CI, 0.24-0.27) in the United States. The microbiology of peritonitis was similar across countries, except in Thailand, where Gram-negative infections and culture-negative peritonitis were more common. Facility size was positively associated with risk for peritonitis in Japan (rate ratio [RR] per 10 patients, 1.07; 95% CI, 1.04-1.09). Lower peritonitis risk was observed in facilities that had higher automated PD use (RR per 10 percentage points greater, 0.95; 95% CI, 0.91-1.00), facilities that used antibiotics at catheter insertion (RR, 0.83; 95% CI, 0.69-0.99), and facilities with PD training duration of 6 or more (vs 6) days (RR, 0.81; 95% CI, 0.68-0.96). Lower peritonitis risk was seen in facilities that used topical exit-site mupirocin or aminoglycoside ointment, but this association did not achieve conventional levels of statistical significance (RR, 0.79; 95% CI, 0.62-1.01).Sampling variation, selection bias (rate estimates), and residual confounding (associations).Important international differences exist in the risk for peritonitis that may result from varied and potentially modifiable treatment practices. These findings may inform future guidelines in potentially setting lower maximally acceptable peritonitis rates.

Intraperitoneal vancomycin is the first-line therapy in the management of peritoneal dialysis (PD)-related peritonitis. However, due to the paucity of data, vancomycin dosing for peritonitis in patients on automated peritoneal dialysis (APD) is empiric and based on clinical experience rather than evidence. Studies in continuous ambulatory peritoneal dialysis (CAPD) patients have been used to provide guidelines for dosing and are often extrapolated for APD use, but it is unclear whether this is appropriate. This review summarizes the available pharmacokinetic data used to inform optimal dosing in patients on CAPD or APD. The determinants of vancomycin disposition and pharmacodynamic effects are critically summarized, knowledge gaps explored, and a vancomycin dosing algorithm in PD patients is proposed.

Patriarchal constructsordain male dominance over female lifestyle and livelihood, additionallydetermining feminine value: more specifically what should happen with, and to, awoman's body. Outlined within Renaissanceproductions such as Thomas Middleton’s WomenBeware Women and The Changeling, possessiveinequality lies behind each woman taken by her rapist. Early laws such as the 1275 Statute of Westminster liken rape to theft and help fashionthe practice to be resultant of female Edenic flaw. Thus, both culture and law reveal the trivializationof rape through the necessity of possession. Rape and other sexual inequities become justifiable as a requisite rightof the man, and part of the natural order to satisfy the woman. Throughout culture and law, rape and chastity expectations demonstratethe need for men to “purify” male dominated societies of women that "drivemen" to sexual compulsion. Women arerepresentative of societal atrocities--manifestations of patriarchal fearspertaining to the loss of power. Purgingsociety of supposed forces proves a valuable service to patriarchal order, as aloss of these controls over the woman could prove disastrous. Thus, in order for the familial and societalpatriarchy to maintain stability, it is the right of the man to exercise his jurisdiction. Because women are possessions, theirviolation directly relates back to their possessors; therefore, the woman’snatural propensity to be ravished, elicits a man’s cultural predisposition topossess. Ultimately, these texts expose possession as the factor used to justify man’s desire to rape, and denote the woman’s fault in her own rape. The act of rape is a political means of advancement in a culture filled with women in need of being ruled. Thus, patriarchal construct requires rule over sexuality, which must be regulated to protect women, the men that possess them, and the patriarchal society as a whole.

Rationale & Objective Peritoneal dialysis (PD)-associated peritonitis is a significant PD-related complication. We describe the likelihood of cure after a peritonitis episode, exploring its association with various patient, peritonitis, and treatment characteristics. Study Design Observational prospective cohort study. Setting & Participants 1,631 peritonitis episodes (1,190 patients, 126 facilities) in Australia, New Zealand, Canada, Japan, Thailand, the United Kingdom, and the United States. Exposure Patient characteristics (demographics, patient history, laboratory values), peritonitis characteristics (organism category, concomitant exit-site infection), dialysis center characteristics (use of icodextrin and low glucose degradation product solutions, policies regarding antibiotic self-administration), and peritonitis treatment characteristics (antibiotic used). Outcome Cure, defined as absence of death, transfer to hemodialysis (HD), PD catheter removal, relapse, or recurrent peritonitis within 50 days of a peritonitis episode. Analytical Approach Mixed-effects logistic models. Results Overall, 65% of episodes resulted in a cure. Adjusted odds ratios (AOR) for cure were similar across countries (range, 54%-68%), by age, sex, dialysis vintage, and diabetes status. Compared with Gram-positive peritonitis, the odds of cure were lower for Gram-negative (AOR, 0.41 [95% CI, 0.30-0.57]), polymicrobial (AOR, 0.30 [95% CI, 0.20-0.47]), and fungal (AOR, 0.01 [95% CI, 0.00-0.07]) peritonitis. Odds of cure were higher with automated PD versus continuous ambulatory PD (AOR, 1.36 [95% CI, 1.02-1.82]), facility icodextrin use (AOR per 10% greater icodextrin use, 1.06 [95% CI, 1.01-1.12]), empirical aminoglycoside use (AOR, 3.95 [95% CI, 1.23-12.68]), and ciprofloxacin use versus ceftazidime use for Gram-negative peritonitis (AOR, 5.73 [95% CI, 1.07-30.61]). Prior peritonitis episodes (AOR, 0.85 [95% CI, 0.74-0.99]) and concomitant exit-site infection (AOR, 0.41 [95% CI, 0.26-0.64]) were associated with a lower odds of cure. Limitations Sample selection may be biased and generalizability may be limited. Residual confounding and confounding by indication limit inferences. Use of facility-level treatment variables may not capture patient-level treatments. Conclusions Outcomes after peritonitis vary by patient characteristics, peritonitis characteristics, and modifiable peritonitis treatment practices. Differences in the odds of cure across infecting organisms and antibiotic regimens suggest that organism-specific treatment considerations warrant further investigation.

Background:Peritoneal dialysis (PD)-associated peritonitis carries significant morbidity, mortality, and is a leading cause of PD technique failure. This study aimed to assess the scope and variability of PD-associated peritonitis reported in randomized trials and observational studies.Methods:Cochrane Controlled Register of Trials, MEDLINE, and Embase were searched from 2007 to June 2018 for randomized trials and observational studies in adult and pediatric patients on PD that reported PD-associated peritonitis as a primary outcome or as a part of composite primary outcome. We assessed the peritonitis definitions used, characteristics of peritonitis, and outcome reporting and analysis.Results:Seventy-seven studies were included, three were randomized trials. Thirty-eight (49%) of the included studies were registry-based observational studies. Twenty-nine percent ( n = 22) of the studies did not specify how PD-associated peritonitis was defined. Among those providing a definition of peritonitis, three components were reported: effluent cell count ( n = 42, 54%), clinical features consistent with peritonitis (e.g. abdominal pain and/or cloudy dialysis effluent) ( n = 35, 45%), and positive effluent culture ( n = 19, 25%). Of those components, 1 was required to make the diagnosis in 6 studies (8%), 2 out of 2 were required in 22 studies (29%), 2 out of 3 in 11 studies (14%), and 3 out of 3 in 4 studies (5%). Peritonitis characteristics and outcomes reported across studies included culture-negative peritonitis ( n = 47, 61%), refractory peritonitis ( n = 42, 55%), repeat peritonitis ( n = 9, 12%), relapsing peritonitis ( n = 5, 7%), concomitant exit site ( n = 16, 21%), and tunnel infections ( n = 8, 10%). Peritonitis-related hospitalization was reported in 38% of the studies ( n = 29), and peritonitis-related mortality was variably defined and reported in 55% of the studies ( n = 42). Peritonitis rate was most frequently reported as episodes per patient year ( n = 40, 52%).Conclusion:Large variability exists in the definitions, methods of reporting, and analysis of PD-associated peritonitis across trials and observational studies. Standardizing definitions for reporting of peritonitis and associated outcomes will better enable assessment of the comparative effect of interventions on peritonitis. This will facilitate continuous quality improvement measures through reliable benchmarking of this patient-important outcome across centers and countries.

Preparation for home dialysis begins with a robust modality education program because patients cannot make a decision regarding the type of dialysis if they are not provided adequate information. This requires infrastructure that some programs do not have, as well as nephrologists who are welcoming and receptive to their patients' choice of home dialysis. Unfortunately, many dialysis patients in the US do not recall receiving much information about peritoneal dialysis (PD), indicating that the process is often inadequate. This is one barrier to PD. Another is the nephrologist. The nephrologist is the most important influence regarding the decision for PD, so it is critically important that the nephrologist be trained in PD sufficiently to eliminate biases. The program must have the infrastructure to provide robust and comprehensive modality education to patients and their support persons. This includes a one-on-one session with an educator (often a nurse), videos, visits to a home program, peer-to-peer discussion with a PD patient, and follow-up with the nephrologist. Because many patients with advanced chronic kidney disease present urgently with signs and symptoms that require rapid dialysis implementation, an in-house education program is desirable but requires an investment in a nurse educator on site. Once the decision is made to start PD, arrangements are made for PD catheter placement. In most centers, scheduling this procedure can be delayed, so careful planning is necessary. Some innovative programs incorporate interventional nephrologists or radiologists in the program who can place PD catheters and thus ensure that rapid start PD is available. These approaches have been shown to greatly increase PD program size and allow a higher proportion of patients to choose PD at the outset. Use of the buried catheter technique is another approach that may facilitate timely PD start. The home dialysis program must be supported by the dialysis provider or hospital or institution, as appropriate. Adequate staffing is critical to the success of the program, allowing time for training (which is usually one on one), and for meeting the regulations in place for home programs. Space for the home program is also essential, with room for private training and for clinic visits.

BackgroundPeritoneal dialysis (PD)-related infections lead to significant morbidity. The International Society for Peritoneal Dialysis (ISPD) guidelines for the prevention and treatment of PD-related infections are based on variable evidence. We describe practice patterns across facilities participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS).MethodsPDOPPS, a prospective cohort study, enrolled nationally representative samples of PD patients in Australia/New Zealand (ANZ), Canada, Thailand, Japan, the UK and the USA. Data on PD-related infection prevention and treatment practices across facilities were obtained from a survey of medical directors’.ResultsA total of 170 centers, caring for >11 000 patients, were included. The proportion of facilities reporting antibiotic administration at the time of PD catheter insertion was lowest in the USA (63%) and highest in Canada and the UK (100%). Exit-site antimicrobial prophylaxis was variably used across countries, with Japan (4%) and Thailand (28%) having the lowest proportions. Exit-site mupirocin was the predominant exit-site prophylactic strategy in ANZ (56%), Canada (50%) and the UK (47%), while exit-site aminoglycosides were more common in the USA (72%). Empiric Gram-positive peritonitis treatment with vancomycin was most common in the UK (88%) and USA (83%) compared with 10–45% elsewhere. Empiric Gram-negative peritonitis treatment with aminoglycoside therapy was highest in ANZ (72%) and the UK (77%) compared with 10–45% elsewhere.ConclusionsVariation in PD-related infection prevention and treatment strategies exist across countries with limited uptake of ISPD guideline recommendations. Further work will aim to understand the impact these differences have on the wide variation in infection risk between facilities and other clinically relevant PD outcomes.

Early innovations in the delivery of peritoneal dialysis (PD) markedly improved its acceptability and lowered peritonitis rates. The standard osmotic agent was, and continues to be dextrose, an agent that is not ideal as it is readily absorbed. The development of icodextrin-containing dialysis fluid has allowed a long dwell time to provide more effective ultrafiltration. The development of a smaller, more easily used automated cycler, led to an increase in the proportion of patients on the cycler as opposed to CAPD. Recently, new cyclers with better teaching tools and ease of use and communication with the training team have come on the market; data on outcomes using these cyclers are not yet available. Peritonitis continues to be a serious complication of PD although improvements in connectology and research on Staphylococcus aureus carriage have decreased peritonitis risk. Peritonitis rates continue to vary tremendously from one program to another, which may be in part due to failure to follow best demonstrated practices in training, care of the l catheter exit site, and prevention of peritonitis. Peritonitis rates should be expressed as episodes per year at risk and as organism-specific rates to allow comparisons from one program to another, from one period to another and from a program to the published literature. The term technique failure is misused in PD. Patients leave PD for a host of reasons including transplantation. Transfer from PD to hemodialysis can be planned and have an excellent outcome or can be delayed or done emergently and have a less optimal outcome. The life plan of the patient with ESRD needs to be not only considered but also periodically revised as circumstances and patient wishes change.

Noninfectious complications of peritoneal dialysis (PD) remain an important impediment to successful implementation of PD. Rare noninfectious complications of the PD catheter are sparsely reported. We report an unusual complication of outflow failure due to a peritoneal catheter that separated into two distinct intra-abdominal segments, due to an unusual method of placement in which two catheters were connected to make a long intra-abdominal portion to permit a high exit site on the abdominal wall. The application of this unusual rather a unique technique led to separation of the two catheter portions and the outflow failure shortly after the patient started continuous ambulatory PD. We reviewed other unusual causes of PD catheter failure, and these included luminal stones blocking the PD catheter, pneumomediastinum related to inappropriate technique, catheter deformation and leak due to the use of antibiotic ointment at the exit site of polyurethane catheters, vesicoperitoneal fistula and perforation of the bladder from the placement of PD catheters, rare site migrations of the catheter, and subcutaneous titanium connector infection in a presternal catheter. Knowledge of these unusual complications may allow prevention and/or early recognition.

BACKGROUND Data on hemodialysis (HD)-related organism specific bacteremia rates by type of access over an extended period are scant in the literature. Using a registry data base we examined all positive blood cultures by organisms for each type of HD access over 14 years. METHODS The IRB-approved registry data collection of prevalent patients at our HD unit from 1/1/1999 through 12/31/2012 was analyzed. All positive blood cultures were recorded and expressed as episodes/1,000 days by access type: arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (CVC). RESULTS The rate of positive blood cultures in patients with CVCs was 1.86/1,000 days and was much higher than in patients with an AVF (0.08/1,000 days, p

Peritonitis is the leading cause of transfer from peritoneal dialysis (PD) to hemodialysis (HD). It is also the leading cause of hospitalization of PD patients. The usual treatment of peritonitis for automated PD (APD) patients consists of antibiotics given once daily in the long dwell. However, the once-daily antibiotic dosing recommendations are based primarily on studies with continuous ambulatory PD (CAPD) regimens. Published studies on antibiotic dosing in APD are very limited. We will review the scant literature on this topic. It is possible that extrapolating once-daily dosing from CAPD to APD may lead to underdosing. There is a need for further pharmacokinetic studies of antibiotic dosing in APD.

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) carries high mortality rates, and disparities have been reported between Caucasian and African American (AA) patients. But little large-scale data are available to examine such differences. The purpose of this study is to compare demographics and mortality outcomes for Caucasian and AA aSAH subjects using both nationwide and midsouth regional datasets. Methods: The nationwide sample was selected from inpatient Cerner Health Facts EMR data made available through UTHSC Center for Biomedical Informatics. The midsouth regional sample was selected from the Semmes Murphey neurosurgical clinic EMR. All subjects were selected by ICD-9 code and were seen from 2004-2016. Available demographics included age, race, gender, and admission Glasgow Coma Scale (GCS) score. Primary outcome was mortality at any time in the first month post-admission. Descriptive statistics were calculated and associations with mortality outcomes examined using t-tests, chi squares, and ANOVA as appropriate. Significance was set at p ≤0.05. Results: In the nationwide dataset (N=3,924, 24% AA, 57% female), AA aSAH patients were nearly 8 years younger than Caucasians (mean age 53.7 ± 17.6 vs 61.4 ± 18.9, p p p p =0.16). Despite an improvement in these demographic disparities locally, regional AA have similar GCS scores as the nationwide sample ( p =0.85) and are more likely than Caucasians to die within 1 month of admission regionally ( p =0.003) and nationwide ( p =0.0007). Conclusions: AA aSAH patients experience increased mortality as compared to Caucasians both nationwide and regionally. From this limited observational data it is not clear what other factors could be contributing to these disparities in mortality. Future work in such disparities should include more complete demographic and clinical data, information on health services access, quality, and utilization, and preexisting comorbidities.

Background Daily gentamicin cream exit-site prophylaxis reduces peritoneal dialysis (PD)-related gram-negative infections. However, there is a concern about the potential for increasing gentamicin resistance with the long-term use of prophylactic gentamicin. This study evaluated the incidence of gentamicin-resistant PD-related infections over more than 2 decades. Methods Study data on prevalent PD patients were retrieved from a prospectively maintained institutional review board (IRB)-approved PD registry at a single center from January 1, 1991, to December 31, 2000, and January 1, 2004, to December 31, 2013. The rates of gram-negative infections, fungal infections and those infections with organisms resistant to gentamicin were examined for the 2 periods. Period 1 from 1991 to 2000 when S. aureus prophylaxis consisted initially of oral rifampin to treat nasal carriage with S. aureus, and was then daily exit-site mupirocin ointment for all PD patients, was compared to the period from 2004 to 2013 when daily exit-site gentamicin cream was prescribed as prophylaxis (Period 2). Results The study included a total of 444 PD patients (265 and 179 in Period 1 and Period 2, respectively). No significant difference was noted in demographics between the 2 periods except race. The gram-negative exit-site infection rates for Period 1 and Period 2 were 0.109 versus 0.027 ( p < 0.0001). Gram-negative peritonitis rates were similar. There were 3 episodes of gentamicin-resistant infections in each period. Fungal infections remained consistently low. Conclusion Despite a decade of exit-site gentamicin prophylaxis, gentamicin-resistant PD-related infections and fungal infections remained very low and similar to the prior period.

The peritoneal dialysis (PD) patient population has grown rapidly in the past few years with concern over poor early outcomes. We report 6-month outcomes of incident PD patients in an experienced program with a strong focus on quality care. We analyzed data from an Institutional Review Board (IRB)- approved registry of all incident PD patients from January 1, 1991, to December 31, 2013, with follow-up to June 30, 2014. Time at risk began on the first day of training. Age, gender, race, diabetes mellitus (DM), Charlson comorbidity index (CCI), and albumin were collected at PD start. Exit-site infection (ESI), peritonitis, hospitalizations, and reasons for stopping PD were recorded. Multivariate analysis was done to examine outcomes.

IN BRIEF Patients with type 2 diabetes have an increased risk for cardiovascular and chronic kidney disease. Superimposed hypertension further increases the risk and is associated with increased dietary sodium intake. There are few data available on dietary sodium intake in type 2 diabetes. The aim of this study was to quantify dietary sodium intake in a cohort of self-referred patients with type 2 diabetes and to identify sociodemographic characteristics associated with it. Sodium intake in this cohort was far greater than current recommendations. Increased awareness of sodium intake in this population might lead to target interventions to reduce sodium intake and potentially improve long-term outcomes.

♦ Objective: The objective of our research was to summarize and review evidence supporting a causal relationship between exit-site infection and peritonitis in peritoneal dialysis (PD) patients.

Objective To evaluate the efficacy of behavioral counseling combined with technology-based self-monitoring for sodium restriction in hemodialysis (HD) patients. Design Randomized clinical trial. Subjects English literate adults undergoing outpatient, in-center intermittent HD for at least 3 months. Interventions Over a 16-week period, both the intervention and the attention control groups were shown 6 educational modules on the HD diet. The intervention group also received social cognitive theory–based behavioral counseling and monitored their diets daily using handheld computers. Main Outcome Measures Average daily interdialytic weight gain (IDWG A ) was calculated for every week of HD treatment over the observation period by subtracting the post-dialysis weight at the previous treatment time (t-1) from the pre-dialysis weight at the current treatment time (t), dividing by the number of days between treatments. Three 24-hour dietary recalls were obtained at baseline, 8 weeks, and 16 weeks and evaluated using the Nutrient Data System for Research. Results A total of 179 participants were randomized, and 160 (89.4%) completed final measurements. IDWG A did not differ significantly by treatment group at any time point considered ( P > .79 for each). A significant differential change in dietary sodium intake observed at 8 weeks (−372 mg/day; P = .05) was not sustained at 16 weeks (−191 mg/day; P = .32). Conclusion The BalanceWise Study intervention appeared to be feasible and acceptable to HD patients although IDWG A was unchanged and the desired behavioral changes observed at 8 weeks were not sustained. Unmeasured factors may have contributed to the mixed findings, and further research is needed to identify the appropriate patients for such interventions.

Behavioral research to improve lifestyle in broadly defined populations of patients with type 2 diabetes is limited.We evaluated a behavioral intervention featuring technology-based self-monitoring on biophysiologic outcomes of glycemic control and markers of cardiovascular risk.In this single-site, randomized clinical trial, participants were stratified by good and poor glycemic control (glycated hemoglobin8% or ≥8%) and absence or presence of kidney disease, (estimated glomerular filtration rate ≥60 or60 mL/min) and randomized within strata. Measurements were obtained at 0, 3, and 6 months.Self-referred, community-dwelling adults with type 2 diabetes mellitus.The intervention group received Social Cognitive Theory-based counseling paired with technology-based self-monitoring, and results were compared with an attention control group.Glycated hemoglobin, fasting serum glucose, lipid levels, blood pressure, weight, body mass index, and waist circumference were evaluated.Mean differences within and between randomization groups were compared over time. Intervention effects over time were estimated using random intercept models.Two hundred ninety-six subjects were randomized, 256 (86.5%) completed 3-month and 246 (83.1%) completed 6-month assessments. Glycated hemoglobin was reduced in the intervention group by 0.5% at 3 months and 0.6% at 6 months (P0.001 for each), and the control group by 0.3% (P0.001) at 3 months and 0.2% (P0.05) at 6 months; but between-group differences were not significant. In those with baseline glycated hemoglobin ≥8% and estimated glomerular filtration rate ≥60 mL/min, glycated hemoglobin was reduced in the intervention group by 1.5% at 3 months and 1.8% at 6 months (P0.001 for each), and the control group by 0.9% (P0.001) at 3 months and 0.8% (P0.05) at 6 months; but between-group differences were not significant. In random intercept models, the estimated reduction in glycated hemoglobin of 0.29% was not significant.Two behavioral approaches to improving general lifestyle management in individuals with type 2 diabetes mellitus were effective in improving glycemic control, but no significant between-group differences were observed.

Methicillin-resistant Staphylococcus aureus (MRSA) can cause severe infections in patients undergoing haemodialysis. Routine periodic testing of haemodialysis patients and attempting to decolonize those who test positive may be a strategy to prevent MRSA infections. The economic value of such a strategy has not yet been estimated. We constructed a Markov computer simulation model to evaluate the economic value of employing routine testing (agar-based or PCR) at different MRSA prevalence, spontaneous clearance, costs of decolonization and decolonization success rates, performed every 3, 6 or 12 months. The model showed periodic MRSA surveillance with either test to be cost-effective (incremental cost-effectiveness ratio ≤$50 000/quality-adjusted life-year) for all conditions tested. Agar surveillance was dominant (i.e. less costly and more effective) at an MRSA prevalence ≥10% and a decolonization success rate ≥25% for all decolonization treatment costs tested with no spontaneous clearance. PCR surveillance was dominant when the MRSA prevalence was ≥20% and decolonization success rate was ≥75% with no spontaneous clearance. Routine periodic testing and decolonization of haemodialysis patients for MRSA may be a cost-effective strategy over a wide range of MRSA prevalences, decolonization success rates, and testing intervals.

The prevalence of and mortality from chronic kidney disease (CKD) are high among African Americans. Interventions to improve knowledge of the likely illness course and the benefits and risks of life-sustaining treatment at the end-of-life are needed for African Americans with CKD and their surrogate decision makers. Nineteen African Americans with stage 5 CKD and their surrogates were randomized to either patient-centered advance care planning (PC-ACP) or usual care. PC-ACP dyads showed greater improvement in congruence in end-of-life treatment preferences (p.05) and higher perceived quality of communication (p.05) than do control dyads, but the two groups did not differ on other primary outcomes or acceptability measures, such as perceptions of cultural appropriateness. At posttest, 80% of patients in the intervention group reported that they would choose to continue all life-sustaining treatments in a situation of a low chance of survival, whereas 28.6% of patients in the control group reported that they would make that choice. At posttest, 90% of patients in the intervention group reported that they would choose to undergo cardiopulmonary resuscitation even if the chance of surviving the attempt would be low, whereas 57% of patients in the control group reported that they would make that choice. PC-ACP can be effective in improving patient and surrogate congruence in end-of-life treatment preferences. However, the results suggest a need for further improvements in the intervention to enhance cultural appropriateness for African Americans with CKD.

Objective We identified factors that account for differences between lean body mass computed from creatinine kinetics (LBM cr ) and from either body water (LBM V ) or body mass index (LBM BMI ) in patients on continuous peritoneal dialysis (CPD). Design We compared the LBM cr and LBM V or LBM BMI in hypothetical subjects and actual CPD patients. Patients We studied 439 CPD patients in Albuquerque, Pittsburgh, and Toronto, with 925 clearance studies. Intervention Creatinine production was estimated using formulas derived in CPD patients. Body water (V) was estimated from anthropometric formulas. We calculated LBM BMI from a formula that estimates body composition based on body mass index. In hypothetical subjects, LBM values were calculated by varying the determinants of body composition (gender, diabetic status, age, weight, and height) one at a time, while the other determinants were kept constant. In actual CPD patients, multiple linear regression and logistic regression were used to identify factors associated with differences in the estimates of LBM (LBM cr V , or LBM cr BMI ). Main Outcome Measure We sought predictors of the differences LBM V – LBM cr and LBM BMI – LBM cr . Results Both LBM V (regardless of formula used to estimate V) and LBM BMI exceeded LBM cr in hypothetical subjects with average body compositions. The sources of differences between LBM estimates in this group involved differences in the coefficients assigned to gender, age, height, weight, presence or absence of diabetes, and serum creatinine concentration. In CPD patients, mean LBM V or LBM BMI exceeded mean LBM cr by 6.2 to 6.9 kg. For example, the LBM V obtained from one anthropometric formula was 50.4±10.4 kg and the LBM cr was 44.1±13.6 kg ( P cr >LBM V . The differences in determinants of body composition between groups with high versus low LBM cr were similar in hypothetical and actual CPD patients. Multivariate analysis in actual CPD patients identified serum creatinine, height, age, gender, weight, and body mass index as predictors of the differences LBM V −LBM cr and LBM BMI −LBM cr . Conclusions Overhydration is not the sole factor accounting for the differences between LBM cr and either LBM V or LBM BMI in CPD patients. These differences also stem from the coefficients assigned to major determinants of body composition by the formulas estimating LBM.

8. Vickery S, Price CP, John RI et al. B-type natriuretic peptide (BNP) and amino-terminal proBNP in patients with CKD: relationship to renal function and left ventricular hypertrophy. Am J Kidney Dis 2005; 46: 610–620 9. Haug C, Metzele A, Steffgen J et al. Changes in brain natriuretic peptide and atrial natriuretic peptide plasma concentrations during hemodialysis in patients with chronic renal failure. Horm Metab Res 1994; 26: 246–249 10. Gangji AS, Helal BA, Churchill DN et al. Association between Nterminal propeptide B-type natriuretic peptide and markers of hypervolemia. Perit Dial Int 2008; 28: 308–311 11. Enia G, Mallamaci F, Benedetto FA et al. Long-term CAPD patients are volume expanded and display more severe left ventricular hypertrophy than haemodialysis patients. Nephrol Dial Transplant 2001; 16: 1459–1464 12. Paniagua R, Amato D, Vonesh E et al. Predictive value of natriuretic peptides in patients on peritoneal dialysis: results from the ADEMEX trial. Clin J Am Soc Nephrol 2008; 3: 407–415 13. Schleiffer T, Nagel D, Franz H et al. Endothelin and atrial natriuretic peptide in non-insulin-dependent diabetic versus nondiabetic patients on chronic hemodialysis. Ren Fail 1994; 16: 747– 758 14. Clerico A, Recchia FA, Passino C et al. Cardiac endocrine function is an essential component of the homeostatic regulation network: physiological and clinical implications. Am J Physiol Heart Circ Physiol 2006; 290: H17–H29 15. Gunal AI, Ilkay E, Kirciman E et al. Blood pressure control and left ventricular hypertrophy in long-term CAPD and hemodialysis patients: a cross-sectional study. Perit Dial Int 2003; 23: 563–567 16. Struijk DG. Volume status in CAPD and APD: does treatment modality matter and is more always better?. Perit Dial Int 2007; 27: 641–644 17. Rodriguez-Carmona A, Perez-Fontan M, Garca-Naveiro R et al. Compared time profiles of ultrafiltration, sodium removal, and renal function in incident CAPD and automated peritoneal dialysis patients. Am J Kidney Dis 2004; 44: 132–145 18. Johnson DW, Dent H, Hawley CM et al. Association of dialysis modality and cardiovascular mortality in incident dialysis patients. Clin J Am Soc Nephrol 2009; 4: 1620–1628 19. Locatelli F, Marcelli D, Conte F et al. Survival and development of cardiovascular disease by modality of treatment in patients with end-stage renal disease. J Am Soc Nephrol 2001; 12: 2411–2417 20. Foley RN, Parfrey PS, Harnett JD et al. Mode of dialysis therapy and mortality in end-stage renal disease. J Am Soc Nephrol 1998; 9: 267–276

This randomized controlled trial tested an intervention, Sharing Patients’ Illness Representations to Increase Trust (SPIRIT), designed to enhance communication regarding end-of-life care between African Americans with end-stage renal disease (ESRD) and their chosen surrogate decision makers (N = 58 dyads). We used surveys and semi-structured interviews to determine the feasibility, acceptability, and preliminary effects of SPIRIT on patient and surrogate outcomes at 1 week and 3 months post-intervention. We also evaluated patients’ deaths and surrogates’ end-of-life decision making to assess surrogates’ perceptions of benefits and limitations of the SPIRIT while facing end-of-life decisions. We found that SPIRIT promoted communication between patients and their surrogates and was effective and well received by the participants.

Both peritoneal dialysis (PD) and hemodialysis (HD) patients have diminished quality of life (QOL) scores compared to healthy patients. QOL tends to decline over time, with the perception of the quality of physical health deteriorating more than mental health. However, many patients continue to feel hopeless, anxious, and worry about finances, loss of sexual function, family burden, and loss of independence. Depression is the most widely acknowledged psychosocial factor seen in patients with chronic kidney disease. Major depression occurs in 25% of patients facing impending dialysis. Once on PD, the proportion with major depression sharply declines to approximately 6%. This may be due to adjustment to dialysis, but may also be because depressive symptoms are associated with an increased risk of death. A low QOL score and depression are associated with higher comorbidity, poorer nutritional status, anemia, lower residual renal function, and increased hospitalization rates. Increased depressive scores are independently predictive of an elevated peritonitis risk, perhaps due to inattentiveness, or alternatively from a decrease in immune defenses. Small molecule clearances appear to have little to do with depressive symptoms. Depression is a significant problem in PD and other dialysis patients. There is an interrelationship between psychosocial factors, perception of illness, and clinical outcome that requires further study. Serial and simple measures of both depression and QOL should be obtained routinely in all PD patients. This permits rapid recognition of problems and may enhance patients' education on the importance of depression. Further research on interventions is urgently needed.

Sleep-disordered breathing (SDB) has been noted commonly in hemodialysis (HD) patients, but it is not known whether this is related directly to the treatment of kidney failure with HD or to the higher prevalence of obesity and older age. Forty-six HD patients were compared with 137 participants from the Sleep Heart Health Study (SHHS) who were matched for age, gender, body mass index (BMI), and race. Home unattended polysomnography was performed and scored using similar protocols. The study sample was 62.7 +/- 10.1 yr, was predominantly male (72%) and white (63%), and had an average BMI of 28 +/- 5.3 kg/m(2). The HD sample had a higher systolic BP (137 versus 121 mmHg; P0.01) and a higher prevalence of diabetes (33 versus 9%; P0.01) and cardiovascular disease (33 versus 13%; P0.01) compared with the SHHS sample. The HD group had significantly less sleep time (320 versus 379 min; P0.0001) but similar sleep efficiency. HD patients had a higher frequency of arousals per hour (25.1 versus 17.1; P0.0001) and apnea-hypopneas per hour (27.2 versus 15.2; P0.0001) and greater percentage of the total sleep time below an oxygen saturation of 90% (7.2 versus 1.8; P0.0001). HD patients were more likely to have severe SDB (30 respiratory events per hour) compared with the SHHS sample (odds ratio 4.07; 95% confidence interval 1.83 to 9.07). There was a strong association of HD with severe SDB and nocturnal hypoxemia independent of age, BMI, and the higher prevalence of chronic disease. The potential mechanisms for the higher likelihood of SDB in the HD population must be identified to provide specific prevention and therapy.

Depression is often underrecognized in patients with end-stage renal disease. We interviewed outpatients at an urban dialysis facility using a criterion-based case-finding instrument to assess the rates, clinical correlates and outcomes of depression.The Primary Care Evaluation of Mental Disorders Mood Module and the nine-item Patient Health Questionnaire were used to assess depression. We measured health-related quality of life using the Kidney Disease and Quality of Life Short Form, and medical comorbidities were measured using the Charlson Comorbidity Index. We compared the sociodemographic and clinical characteristics and health-related quality of life of depressed and nondepressed patients using t tests and the chi-square test, and we used a Cox regression model to test the relationship between depression and mortality.We interviewed 62 patients and followed them for a mean of 29 months (range, 0.1-36). Seventeen (28%) had major or minor depression. Depressed patients were younger and had lower health-related quality of life than did nondepressed patients. Depression predicted mortality (HR=4.1, 95% CI=1.5-32.2, P.05) after adjusting for age, gender, race, medical comorbidities, albumin, kt/V and/or the presence of diabetes.Depression is common and associated with decreased health-related quality of life and increased mortality in hemodialysis patients. Clinical trials are necessary to examine whether treatment of depression can improve these outcomes.

Infection is the Achilles heel of peritoneal dialysis. Exit site mupirocin prevents Staphylococcus aureus peritoneal dialysis (PD) infections but does not reduce Pseudomonas aeruginosa or other Gram-negative infections, which are associated with considerable morbidity and sometimes death. Patients from three centers (53% incident to PD and 47% prevalent) were randomized in a double-blinded manner to daily mupirocin or gentamicin cream to the catheter exit site. Infections were tracked prospectively by organism and expressed as episodes per dialysis-year at risk. A total of 133 patients were randomized, 67 to gentamicin and 66 to mupirocin cream. Catheter infection rates were 0.23/yr with gentamicin cream versus 0.54/yr with mupirocin (P = 0.005). Time to first catheter infection was longer using gentamicin (P = 0.03). There were no P. aeruginosa catheter infections using gentamicin compared with 0.11/yr using mupirocin (P < 0.003). S. aureus exit site infections were infrequent in both groups (0.06 and 0.08/yr; P = 0.44). Peritonitis rates were 0.34/yr versus 0.52/yr (P = 0.03), with a striking decrease in Gram-negative peritonitis (0.02/yr versus 0.15/yr; P = 0.003) using gentamicin compared with mupirocin cream, respectively. Gentamicin use was a significant predictor of lower peritonitis rates (relative risk, 0.52; 95% confidence interval, 0.29 to 0.93; P < 0.03), controlling for center and incident versus prevalent patients. Gentamicin cream applied daily to the peritoneal catheter exit site reduced P. aeruginosa and other Gram-negative catheter infections and reduced peritonitis by 35%, particularly Gram-negative organisms. Gentamicin cream was as effective as mupirocin in preventing S. aureus infections. Daily gentamicin cream at the exit site should be the prophylaxis of choice for PD patients.

he 2 seminal accomplishments in the 62-yearhistory of the National Kidney Foundation(NKF) are US Public Law 92603 of 1972, amend-ing the Social Security Act to establish Medicarecoverage for both dialysis and kidney transplantation,and publication of the KDOQI (Kidney Disease Out-comes Quality Initiative) clinical practice guidelinesfor chronic kidney disease (CKD) in February 2002.

Both peritonitis and serum albumin level are associated with morbidity and mortality in peritoneal dialysis (PD) patients. Severe cases of peritonitis result in hypoalbuminemia. However, it is not clear whether hypoalbuminemia predicts the development of peritonitis.We performed a retrospective analysis of a prospectively collected database from six centers in western Pennsylvania and West Virginia. Incident PD patients with a Charlson Comorbidity Index (CCI) score at the start of PD therapy and serum albumin level measured within 30 days of initiation were selected. Poisson regression was used to analyze predictors of peritonitis.Three hundred ninety-three patients had a CCI score and serum albumin level measured at the start of PD therapy. Overall peritonitis rate was 0.65 episodes/dialysis-year. Significant univariate predictors were albumin level (rate ratio [RR], 0.79 per 1-g/dL [10-g/L] increase; 95% confidence interval [CI], 0.65 to 0.95; P = 0.015), male sex (P = 0.003), and being dialyzed in the Veterans Administration (RR, 1.97; 95% CI, 1.48 to 2.62; P0.001) or other center (RR, 1.68; 95% CI, 1.92 to 5.62; P0.001). Although CCI score correlated inversely with albumin level (r = -0.305; P0.001), CCI score was only marginally predictive of peritonitis (P = 0.068). In multivariate analysis, predictors were albumin level (RR, 0.74; 95% CI, 0.31 to 1.75; P = 0.002) and race (RR, 1.36; P = 0.024). Patients with an initial serum albumin level less than 2.9 g/dL (29 g/L) had a peritonitis rate of 1.5 episodes/dialysis-year compared with 0.6 episodes/dialysis-year for patients with an initial serum albumin level of 2.9 g/dL or greater (P0.001).Hypoalbuminemia at the start of PD therapy is an independent predictor of subsequent peritonitis. Intervention studies to decrease peritonitis risk in this high-risk subset of patients are needed.

A 63-year-old man on ambulatory peritoneal dialysis (APD) developed peritonitis with Enterococcus faecalis, treated with 2 g intraperitoneal (IP) vancomycin, with rapid clearing of the effluent white blood cells, but persistence of positive cultures. Vancomycin was redosed on day 8 (2 g IP), and then weekly. Gentamicin 140 mg IP loading dose, followed by 40 mg IP once a day was added after cultures were still positive at 2 weeks. The two drugs were continued for six additional weeks. Although the patient was asymptomatic, the effluent cultures continued to grow E. faecalis and the catheter was replaced 2 months after the onset of peritonitis. There was no evidence of either tunnel infection or intra-abdominal abscess. Refractory peritonitis is defined as continuation of peritonitis after 5 days of appropriate therapy. This patient had persistently positive cultures but quickly became asymptomatic and signs of inflammation resolved readily. The most likely etiology appears to have been colonization of the slime layer of the intra-abdominal portion of the catheter with the organism. The vancomycin dosing schedule may have played a role in the persistently positive cultures. A recent pharmacokinetic study suggested that patients on APD require 35 mg/kg IP of vancomycin as a loading dose, followed by 15 mg/kg IP once a day, given in a long day exchange. Simultaneous placement and removal as a single procedure was successful in this patient and can be done safely in patients whose effluent white blood cell count (WBC) is less than 100/mm3. Most patients can then be subsequently managed by doing supine dialysis (using a cycler) with decreased exchange volumes and a dry abdomen until healing occurs (usually 1-2 weeks). In this way hemodialysis can be avoided. By minimizing the effect on the patient's lifestyle, the patient is more likely to agree to a catheter exchange.

Automated peritoneal dialysis (APD) is increasingly popular compared to continuous ambulatory peritoneal dialysis (CAPD). It not only can provide more solute clearance and ultrafiltration than its CAPD counterpart, but it is conducive to a more convenient lifestyle as well. Using relatively smaller-volume daytime dwells, with the use of larger-volume exchanges while the patient is recumbent during the night, is an attractive approach. Advantages of supine exchanges include greater small molecule clearances for equivalent flow rates and decreased intra-abdominal pressure per volume of dialysate (as intraperitoneal pressure parallels intraperitoneal volume). Urea nitrogen clearance can be optimally increased on APD by increasing both the exchange volume and the frequency of exchanges at night. This is even true for anuric low transporters. This approach allows daytime exchanges and volumes to be minimized. Historic studies in peritoneal dialysis including flow rate analysis, clearance and adequacy studies, as well as tolerance have primarily involved CAPD. As a result, there is a paucity of investigations involving APD. More research is required in APD related to these subjects.

Cardiovascular disease remains the bane of patients requiring renal replacement therapy. A major element in this grave morbidity profile is the cumulative cardiovascular burden incurred during the long history of chronic kidney disease (CKD). A high proportion of CKD patients present with cardiovascular disease at the time of dialysis initiation, notably left ventricular hypertrophy, coronary artery disease and congestive heart failure (CHF). Data from the United States Renal Data Survey (USRDS) continue to show a high prevalence of congestive heart failure at the time of dialysis initiation in the U.S. end-stage renal disease (ESRD) population, ranging from 30 to 45% of patients depending on age group Figure 1. This prevalence has not changed since 1995. A higher proportion of patients on hemodialysis (HD) have CHF at dialysis initiation and experience hospitalizations due to CHF in the first year on dialysis compared to peritoneal dialysis (PD) patients. Cardiovascular disease in PD patients remains a concern requiring therapeutic focus.

♦ ObjectiveHigher than normal body mass index (BMI) is associated with an increased risk of death in the general population. We examined the effect of higher than normal BMI on patient and technique survival in peritoneal dialysis patients (PD), controlling for comorbidity, initial albumin, dialysate-to-plasma ratio of creatinine (D/PCr), and initial urea clearance (Kt/V).♦ DesignRegistry database.♦ SettingsFour dialysis centers.♦ PatientsIncident PD patients.♦ MethodsAll data were collected prospectively. Demographics, BMI, serum albumin, D/PCr, and comorbidity using the Charlson Comorbidity Index (CCI) were determined at the start of PD. 104 patients with a high BMI (> 27) were matched to a control group of 104 patients with normal BMI (20 – 27) for age, gender, presence of diabetes, and CCI. Patient and technique survival were compared using Cox proportional hazards model.♦ Main Outcome MeasuresPatient and technique survival.♦ ResultsThe groups were of similar age (56.1 vs 56.7 years), sex (60% males in both groups), race (Caucasian 80% vs 86%), presence of diabetes (40% vs 37%), CCI score (5.4 in both groups), initial albumin (3.6 vs 3.5 g/dL), and D/PCr(0.65 in both groups). Kaplan–Meier survival analysis showed similar 2-year patient survival between large BMI (> 27) and control (20 – 27) groups (76.6% vs 76.1%). Two-year technique survival was also similar between the two groups (59.7% vs 66.8%). With Cox proportional hazards analysis, BMI was not a predictor of patient mortality or technique survival when controlling for initial albumin, D/PCr, and initial Kt/V.♦ ConclusionsWe conclude that a BMI above normal is not associated with any increased or decreased risk of death in patients on PD for 2 years.

BACKGROUND Research pertaining to the nutritional intake of hemodialysis patients is limited. PURPOSE Describe the nutritional quality of foods consumed by hemodialysis patients and variation by day of the week. METHODS Dietary recalls were obtained from 22 hemodialysis patients and analyzed using the Nutrition Data System for Research. RESULTS Few statistically significant differences were found by day of the week, but several dietary deficits were noted. CONCLUSION The data suggest poor intake of calories, protein, and several vitamins and minerals, as well as excess sodium consumption, but little variation by day of the week. Additional research is needed.

Hypercalcemia in a Peritoneal Dialysis Patient