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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.

The present study was undertaken to examine the experience of younger dialysis patients with end-stage renal disease (ESRD) care. Structured tape-recorded interviews focusing on perceptions of ESRD care and how that care could be improved were initially conducted with 25 dialysis patients [16 on conventional hemodialysis (HD), 6 on nocturnal in-center HD, 2 on home peritoneal dialysis (PD), and 1 on home HD]. The mean age of the patients was 43.8 +/- 12.2 years, and their mean dialysis duration was 4.6 +/- 3. Oyears. Five important domains were identified from the interviews. Based on those findings, a questionnaire was developed and distributed to 62 ESRD patients (49 on HD, 13 on PD). Several domains were identified that provide insight into how the patients thought their care could be improved. Our results suggest that certain changes in ESRD care might improve the experience of younger dialysis patients.

The role of peritoneal dialysis (PD) in the treatment of end-stage renal disease in elderly patients remains unclear. In the United States, PD is used only to a limited extent in that population. There are concerns about technique failure, including physical and psychosocial limitations and the risks of peritonitis. Thus, we retrospectively reviewed our 22 years of experience with patients 75 years of age and older who started on PD. Basic demographic data were collected, and mortality, technique failure, and peritonitis rates were determined. Quality of life (QOL) was assessed using the SF-36 questionnaire, a global QOL assessment, and a depression questionnaire. Among the 235 patients identified (mean age: 79 +/- 4 years; 51% white; 49% female; mean time on PD: 15.8 +/- 11.5 months), technique failure rates at 12 months were not significantly different for the patients 75 years of age older compared with the patients less than 75 years of age. Mortality rates were significantly higher in elderly patients. The peritonitis rate in patients 75 years of age and older was 1 episode in 23.6 patient-months compared with 1 episode in 23 patient-months in younger patients. The most common gram-positive organisms isolated were Staphylococcus epidermidis (38%0) and S. aureus (50%); gram-negative organisms accounted for 22%, and yeasts, 5% of peritonitis episodes. Reasons for transfer to hemodialysis included psychosocial problems (42%) and peritonitis (25%). Not surprisingly, physical component scores on the SF-36 were lower in the older than in the younger patients, but mental component scores on the SF-36 were slightly better in older than in younger patients, and global QOL and depression scores were not different between the groups. Our data suggest that PD is a reasonable modality for elderly patients.

Utilization of chronic peritoneal dialysis (CPD) continues to decline in the United States. Technique failure remains a key factor in this decline. Center size has been associated with technique failure. Afolalu et al. observed that technique failure rates were higher in units with fewer than 25 patients. We wondered if declining CPD utilization rates are reflective of changes in small or large units. Using the 2000 overall census of individual CPD units in Network #1, New England, between January 1, 2000, and December 31, 2008, we divided the units by size: units with fewer than 25 patients, and units with 25 patients or more. The CPD patient population increased to 1264 patients in 2008 from 1238 patients in 2000 (a 2% increase). A total of 85 units provided CPD therapy in 2000, increasing to 95 units in 2008. Of the 85 units in 2000, 11 managed 25 patients or more. By 2008, 8 of those 11 units had experienced a drop in CPD census. In 2000, larger units had been caring for 547 patients in total; in 2008, larger units were caring for a total of 546 patients. In 2000, 74 units had fewer than 25 patients, and smaller units were caring for a total of 691 patients. By 2008, smaller units were caring for 718 patients in total. Our finding that larger units with 25 patients or more experienced an average decline of 34% in CPD census is a major concern. Growth in the total number of smaller units was not associated with overall CPD growth. Further studies are needed to describe the reasons for decline in CPD census noted in most of the larger units.

Assessment of volume status in patients with end-stage renal disease has long been a problem. Objective tools for estimating dry weight are necessary. The present study was designed to determine if better assessment of volume status could be achieved by measuring brain natriuretic peptide (BNP) and thoracic fluid content (TFC) by bioimpedance. We prospectively surveyed 51 medically stable peritoneal dialysis (PD) patients during their routine visits to our PD facility. There were no exclusion criteria. Clinical volume status was assessed by the attending nephrologist as hypovolemic, euvolemic, or hypervolemic. Once the clinical assessment was complete, plasma BNP concentration was measured. The TFC was determined by bioimpedance cardiography measured in the supine position. Of 51 patients, 19 (37.3%) were considered hypervolemic, 30 (58.8%) euvolemic, and 3 (5.9%) hypovolemic by clinical assessment. As defined by systolic blood pressure > or = 130 mmHg or diastolic pressure > or = 80 mmHg (or both), 57% were hypertensive. The hypovolemic group was excluded from the statistical analysis because of the small sample size. Logistic regression analysis did not show a significant correlation between clinical assessment of volume and BNP (p = 0.76) or TFC (p = 0.39). Our data demonstrate the limitations of BNP and thoracic impedance in helping with the clinical evaluation of volume status in a cohort of chronic PD patients.

The goal of the present case report is to enhance recognition of the incidence of tissue calcifications, which are quite common in patients with end-stage renal disease. We focus on pulmonary metastatic calcifications and the potential progression of this condition to tissue necrosis and lung cavitations in the setting of severe electrolyte imbalance. This case highlights the importance of early identification of the causes and potential risk factors leading to visceral calciphylaxis.

Peritoneal catheter removal may be clinically indicated in the management of peritonitis. The data on the course of patients undergoing peritoneal catheter reinsertion after removal for peritonitis are limited. The present study was designed to examine what happens to patients on chronic peritoneal dialysis (CPD) after peritoneal catheter removal for peritonitis. We retrospectively reviewed the charts of patients who developed peritonitis between January 1, 1990, and September 1, 2002. We identified 1146 episodes of peritonitis; in 189 of the episodes (16%), the peritoneal catheter was removed. Catheters were reinserted in 88 of those patients (47%). Reasons for peritoneal catheter removal among the 88 patients who underwent peritoneal catheter reinsertion included unit protocol (51%), poor response to antibiotics (46%), and exit-site or tunnel infection (3%). Reasons for peritoneal catheter removal among the 101 patients in whom the peritoneal catheter was not reinserted included unit protocol (62%), poor response to antibiotics (20%), and extensive history of peritonitis (18%). After reinsertion, the new peritoneal catheter remained in place for a mean of 15.4 +/- 15.4 months (range: 1-75 months). In 37 of the 88 patients with reinserted peritoneal catheters (42%), the catheters remained in place for longer than 1 year. The remaining 6 patients underwent transplantation or were transferred to another facility. Of the remaining 51 patients whose new peritoneal catheters lastedfor less than I year, 13 (25.5%) died, and 32 (63%) were transferred permanently to hemodialysis. Of the 101 patients who did not have a peritoneal catheter reinserted, 23 (23%) died within the 2-week period following the onset of peritonitis. The rest were transferred to hemodialysis. The reasons noted for not reinserting the peritoneal catheter included frequent episodes of peritonitis, patient unwillingness to retry CPD therapy, psychosocial reasons, bowel perforation, or transfer to an institution unable to perform CPD therapy. We conclude that, among patients who medically require peritoneal catheter removal because of peritonitis, few will successfully return to long-term CPD therapy. Of the patients who required peritoneal catheter removal in our study, 23% died within the first 2 weeks after the onset of peritonitis, before catheter reinsertion could be considered. Only 47% of the patients underwent a successful catheter reinsertion; and, of those, only 34% remained on CPD therapy I year later Thus, only 20% of patients undergoing PD catheter removal remain on CPD therapy 1 year after catheter removal.

Noncompliance (NC) with the dialysis prescription has been described as a common problem in dialysis patients. In previous studies, NC in peritoneal dialysis (PD) patients has been assessed by obtaining patient or family histories, using questionnaires, and making home visits. With the use of the HomeChoice Pro Chip Card (PCC: Baxter Healthcare Corporation, Deerfield, IL, U.S.A.), the dialysis staff can monitor the total volume of dialysate used, the frequency of exchanges, and the duration of dialysis in patients maintained on automated peritoneal dialysis (APD). Last year, we reported that the PCC was an effective tool for assessing compliance and noted that more than half of patients had a compliance rate (CR) < 95%. In the present study, we examined the impact of patient education on compliance with the prescribed dialysis regimen. We evaluated our APD patients for CR with their dialysis prescription. The PCC was used to record the duration of dialysis and the actual volume of fluid used. From October 2002 to September 2003, all patients maintained at home for 3 consecutive months on APD in the New Haven continuous ambulatory peritoneal dialysis unit were educated concerning the importance of compliance with their dialysis regimen. They were also educated about the function of the PCC and were informed that the dialysis facility would be monitoring their compliance with the prescribed regimen. Compliance rates were calculated by dividing the delivered dialysis volume by the prescribed dialysis volume and multiplying by 100. We obtained data on 42 APD patients. Of the 42 patients, 35 (83%) had a CR > or = 95%, 3 (7%) had a CR between 90% and 94.9%, and 4 (10%) had a CR < 90%. Those CRs are much better than the ones we had previously reported, before the institution of the patient education program. The PCC can be used to assess compliance in APD patients. Patient education results in an improvement in patient compliance. Further study is required to determine factors that affect CR in APD patients.

Racial differences have been reported among various groups with end-stage renal disease maintained on dialysis. In particular, patient survival on dialysis has been reported to be better in African-American patients than in Caucasian patients. Peritonitis rates and dropout from chronic peritoneal dialysis (CPD) have been reported to be higher in African-American patients. We decided to review our experience with peritonitis rates in African-American and Caucasian patients. From 1994 to 2000, 403 patients were maintained on CPD in the New Haven continuous ambulatory peritoneal dialysis (CAPD) unit. Peritonitis rates were 1 episode in 14 patient-months in Caucasian patients and 1 episode in 13.6 patient-months in African-American patients. Mean ages at the start of dialysis were 52.4 +/- 16.2 years in the Caucasian patients and 62.6 +/- 14.9 years in the African-American patients. African-American patients were older. African-American and Caucasian patients had similar peritonitis rates. Time of first episode of peritonitis was not different in the two groups.

Numerous reports of quality-of-life data in chronic peritoneal dialysis (CPD) patients in the United States and Western Europe use the short form questionnaire (SF-36). Few centers in Europe have reported data examining the incidence of depression in CPD patients. Depression has been shown to correlate with morbidity and mortality in dialysis patients. A high incidence of clinical depression is seen in end-stage renal disease patients in the United States. We thought it could be important to compare depression measurements between the United States and European countries. Quality-of-life data of the peritoneal dialysis patients from the New Haven continuous ambulatory peritoneal dialysis (CAPD) unit and from the New Technology Center at Hospital #31 in St. Petersburg were compared. The Beck Depression Inventory (BDI) and the SF-36, which includes the mental component score (MCS) and the physical component score (PCS), were administered to the patients. The study participants included 147 Russian and 96 U.S. patients. The BDI, PCS, and MCS scores were similar in both groups. The BDI scores in the Russian patients indicated that a high incidence of clinical depression likely exists in that patient population. The utility of the BDI in assessing quality-of-life issues in Europe and Russia requires further evaluation.

Microbial colonization and infection of dialysis catheters is the major cause of catheter failure. The present study aimed to develop a method to permit the study of microbial biofilm formation and antibiotic prophylaxis and therapy. Standard silicon rubber and silver-impregnated catheters were sectioned into 1 mm slices and placed into 1-cm x 2-cm culture slide chambers. Fresh clinical isolates were obtained from infected patients and suspended in concentrations of 10(3), 10(6), and 10(9) colony forming units (CFU) per milliliter in a variety of liquid suspending culture media, which included serum protein constituents. Antibiotics could be added to the suspending fluid to determine prophylactic activity, or at any time thereafter to determine therapeutic activity. The catheter sections were incubated with the microbial challenge for 6 hours, 12 hours, 24 hours, and 48 hours and then washed in flowing distilled water to remove unattached biofilm. They were then stained with acridine orange, which fluoresces microbial DNA, and were examined by confocal scanning laser microscopy. Biofilm formation, representing colonization and infection, were quantified by comparing the fluorescent pixel analysis of the uninoculated control with the challenged catheter. The method was reproducible and permitted quantitative analysis. Standard silicon rubber catheters demonstrated greater biofilm formation than silver-impregnated catheters. The method examines the factors involved in microbial colonization and infection, and in antibiotic prophylaxis and therapy.

Patients with end-stage renal disease on chronic peritoneal dialysis (CPD) can usually tolerate continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) without abdominal discomfort or pain. In some patients, pain or discomfort occurs with complete drain of the peritoneal dialysis solution or upon initiation of dialysis filling when the peritoneal cavity is empty. We report on the use of tidal peritoneal dialysis (TPD) as a modality to alleviate this pain. Of 136 patients in our CPD unit, 18 (13%) were complaining of pain with complete drain or upon instillation of PD fluid. All were placed on TPD after other causes for abdominal pain were excluded. Six patients were placed on 25% TPD, and 12 patients on 50% TPD. The mean Kt/V of the patients on TPD was 2.46 +/- 0.68. With TPD, all patients had complete relief of abdominal discomfort. Patients who develop abdominal pain with complete drain or fill when the abdominal cavity is empty would benefit from TPD and be able to continue with CPD.

Presently, adequate dialysis in continuous peritoneal dialysis (CPD) patients is assessed by monitoring urea kinetics (Kt/V) or by measuring the total creatinine clearance (CC). Target Dialysis Outcome Quality Initiative (DOQI) goals are a weekly Kt/V of at least 2.0, and a CC of at least 60 L/wk per 1.73 m2. One hundred and four CPD patients in the New Haven continuous ambulatory peritoneal dialysis (CAPD) unit had their most recent Kt/V and CC reviewed. Of these patients, 58.7% attained the DOQI goals for Kt/V and CC, 14.4% had an acceptable Kt/V but low CC, 11.5% had an acceptable CC but low Kt/V, and 15.4% had both low Kt/V and low CC. A CC > 60 L/week per 1.73 m2 was associated with a residual renal function of > 25 L/wk per 1.73 m2. For a Kt/V of > 2.0, good residual renal function was helpful but not essential. A question left unanswered is whether patients with a low Kt/V and an adequate CC or low CC and acceptable Kt/V need more dialysis.

Hyperparathyroidism (HPT) is a common finding in patients with end-stage renal disease (ESRD). Most chronic peritoneal dialysis (CPD) patients with HTP can be successfully managed with phosphate binders, calcium supplements, and calcitriol therapy. Noncompliance with diet, prescribed binder, or calcitriol therapy may also lead to HPT. We reviewed New Haven CAPD unit patients who failed medical therapy and required parathyroidectomy (PTX) for control of severe HPT [sustained immunoreactive parathyroid hormone (iPTH) level > 600 pg/mL]. From 1990 to 1997, 18 out of 620 patients (3.0%) required PTX. Time on dialysis prior to PTX was 44.8 +/- 17.5 (mean +/- SD) months with a range of 13 to 71 months. The mean age was 43.6 +/- 11.8 years with a range of 30 to 66 years. There were 10 females and 8 males. Of the 18 patients, 14 had total parathyroidectomy with arm implants, and 4 had subtotal PTX. Seven of 18 patients had iPTH levels of < 100 pg/mL at 1 year post-PTX (5 patients with arm implants, 2 with subtotal PTX). Three patients required partial arm implant PTX to correct recurrent HPT. Pulse oral calcitriol (POC) was prescribed in 10 patients post PTX to maintain iPTH at target levels. Parathyroidectomy was necessary to correct HPT in 18 of 620 CPD patients from 1990 to 1997. The majority of these patients had excellent results after their PTX. Intact PTH levels of < 100 pg/mL for 1 year or more were noted in 5 of 14 patients with arm implants, and 2 of 4 patients with subtotal PTX. The significance of a persistent iPTH of < 100 pg/mL has yet to be determined in CPD patients.

Many patients with end-stage renal disease (ESRD) require admission to an extended-care facility (ECF). Few data are available concerning the development of peritonitis among continuous peritoneal dialysis (CPD) patients residing in an ECF. We retrospectively reviewed the charts of 77 CPD patients admitted to an ECF between November 1993 and 31 August 1997. A total of 25 episodes of peritonitis developed among CPD patients in the ECF during this period for an overall peritonitis rate of 1 episode in 19.8 patient-months. The CPD patients developing peritonitis in the ECF were similar in age and gender to the CPD patients residing in the ECF not developing peritonitis. There were more African-Americans among the group of CPD patients residing in the ECF who developed peritonitis than among the ECF residents who did not develop peritonitis (41% vs. 23%, respectively; P < 0.05). Patients developing peritonitis in the ECF resided in the ECF significantly longer than the remaining CPD patients not developing peritonitis in the ECF (106 vs. 77 days, respectively; P < 0.05). The overall rate of peritonitis in the ECF was lower than that seen in the community (1 episode in 19.8 patient-months vs. 1 episode in 10.0 patient-months, respectively). The rate of gram-positive peritonitis was lower than the rate of gram-positive peritonitis seen in the community setting (1 episode in 54.9 patient-months vs. 1 episode in 14.9 patient-months, respectively). The rate of culture-negative peritonitis was higher among the ECF patients than among patients developing community-acquired peritonitis (1 episode in 61.9 patient-months vs. 1 episode in 106.2 patient-months, respectively). The spectrum of organisms in the ECF was different than the spectrum noted among patients developing hospital-acquired peritonitis. Eleven of the 25 episodes of peritonitis were treated successfully at the ECF while the remaining 14 episodes of peritonitis were treated at an acute-care hospital. Continuous PD therapy was continued following 19 of the 25 episodes (76%), 1 patient transferred to hemodialysis, and 5 patients expired. We conclude that patients develop peritonitis in the ECF less frequently than in the community setting, with the spectrum of organisms different than the spectrum seen in the community and hospital settings. Seventy-six percent of the patients continue CPD therapy following an episode of peritonitis.

An increasing number of patients are prescribed a continuous-cycling regimen because standard manual peritoneal-dialysis exchanges alone are not sufficient in achieving adequate dialysis as defined by the Dialysis Outcome Quality Initiative. Consequently, the number of patients on continuous-cycler therapy is increasing. There is controversy as to whether there are differences in the development of peritonitis between patients maintained on manual therapy and those on continuous cycling therapy. As a result, we retrospectively reviewed the charts of all cycler peritoneal dialysis (CPD) patients maintained on either manual peritoneal dialysis (Baxter UltraBag; Group I) or continuous cycler peritoneal dialysis (Baxter HomeChoice Cycler; Group II) between 1 June 1994 and 31 December 1996. A total of 239 patients were in Group I and 106 in Group II. Both groups were similar in age, race, gender, and presence of diabetes mellitus, coronary artery disease, peripheral vascular disease, and gastrointestinal disease. There was no difference in the overall rate of peritonitis between the two groups of patients [1 episode in 10.4 patient-months (Group I) vs. 1 in 10.0 patient-months (Group II); -0.01843 to 0.02619]. The rates of Staphylococcus aureus peritonitis [1 episode in 48.5 patient-months (Group I) vs. 1 in 141.8 patient months (Group II); -0.06152 to -1.1689]; polymicrobial peritonitis [1 episode in 278.8 patient-months (Group I) vs. 1 in 1134 patient months (Group II): -0.0079 to -0.0478], and fungal peritonitis (1 episode in 202.7 patient-months (Group I) vs. no episodes (Group II); 0.00202 to 0.00785] were significantly lower among patients maintained on the Baxter HomeChoice Cycler. The rate of gram-negative peritonitis was higher among patients maintained on the Baxter HomeChoice Cycler, but this difference was not statistically significant [1 episode in 82.6 patient-months (Group I) vs. 1 episode in 45.4 patient months (Group II); 0.4723 to -0.0248]. We conclude that individual rates of peritonitis were different for patients maintained on either manual or continuous CPD therapy, while the overall rate of peritonitis was found to be similar for both groups of patients. The finding that there may be a difference with the gram-negative peritonitis rate is important since gram-negative peritonitis has been shown to have a more severe outcome in terms of morbidity, mortality, and patient dropout from CPD therapy. A larger, randomized, multicenter study comparing the rates of gram-positive, gram-negative, fungal, and polymicrobial peritonitis is warranted.

Previous studies by our group have attempted to examine quality of life (QoL) issues in a cohort of end-stage renal disease (ESRD) patients maintained on chronic peritoneal dialysis (CPD) by assessing a variety of psychological tests and by asking patients to rate their own QoL. The present study was undertaken to extend previous observations by asking patients to spontaneously select those domains of life experience that they think are most important in determining their quality of life. Sixty-eight medically stable CPD patients were asked to spontaneously select those three to five domains felt to be most important to them in defining their QoL. The 307 responses were then grouped into 22 broad categories by three investigators. The most frequently selected domains focused on interpersonal relationships. Domains that enhance the quality of one's day and add meaning to one's life were selected with a midrange frequency. Some domains that might intuitively seem to be important for a patient's QoL were selected with a surprisingly low frequency. These findings suggest that to understand what CPD patients value in assessing their QoL can best be determined by asking them directly and not by using predetermined variables.

Patient dropout from chronic peritoneal dialysis (CPD) and transfer to hemodialysis remains a major problem with patients on CPD. Peritonitis, exit-site infections, and medical complications requiring hospitalization often adversely affect the outcome of CPD. The role of psychosocial factors in determining patient outcome and influencing the rates of these complications is not clear. Our group has employed a variety of instruments, including the Patient Related Anxiety Scale (PRAS), Beck's Depression Inventory (BDI), Kupfer-Detre System II somatic symptom scale (KDS-II), and a patient self-assessed quality of life (PAQOL) questionnaire to assess quality of life and to objectively evaluate the psychosocial status of the patient treated with CPD. The present study extends previous observations by relating the results of these psychosocial instruments to the incidence of various complications in 103 patients maintained on CPD. Patients were divided into low-scoring (lowest symptoms of depression, anxiety, somatic symptoms, and best quality of life evaluation), intermediate, and high-scoring (highest symptoms of depression, anxiety, somatic symptoms, and worst quality of life) categories. The peritonitis rates, exit-site infection rates, and days of hospitalization of the three categories were then compared. The results demonstrate significantly higher complication rates in the high-scoring when compared to the low-scoring patients. Thus screening patients maintained on CPD with objective measures of psychosocial functioning may enable caregivers to more accurately predict which patients are at greater risk for developing medical complications.

It has been suggested that psychosocial (PS) factors may influence morbidity and mortality in chronically ill patients. However, investigators have not examined how PS factors affect specific medical problems in chronic peritoneal dialysis (CPD) patients. Sixty-eight patients maintained on CPD therapy were studied. PS testing included a self-rating form of patient-assessed quality of life (PaQOL), depression [Beck's Depression Inventory (BDI)], anxiety [Patient Rated Anxiety Scale (PRAS)], and assessment of physical symptoms (KDS-II). Peritonitis rates six months prior to PS assessment and six months after assessment were tabulated. The data show that during the study period patients with more than one episode of peritonitis compared to those with no episodes of peritonitis had: (1) significantly higher anxiety and physical symptom scores; (2) significantly lower PaQOL; and (3) higher depression scores, which did not reach statistical significance (p < 0.06). Whether higher peritonitis rates result in worse PS symptoms, or whether poor PS symptoms cause higher peritonitis rates needs to be determined with further investigations.

Previous studies have shown the incidence of peritonitis to be generally lower for patients performing continuous cycling peritoneal dialysis (CCPD) than patients maintained on continuous ambulatory peritoneal dialysis (CAPD). Recent changes in CAPD techniques, particularly the introduction of the UltraBag system, have resulted in a marked decrease in peritonitis rates in CAPD patients. The purpose of the present study was to compare peritoneal dialysis-related infections in 73 patients treated with CCPD and 57 patients treated with CAPD using the UltraBag system for a 12-month period. Demographic data of the two groups were comparable. Peritonitis rates were significantly lower in the patients treated with CAPD on the UltraBag (one infection/23 patient-months) than in patients treated with CCPD (one infection/14.4 patient-months, p < 0.05). Exit-site infections were also significantly lower in patients treated with CAPD (one episode/35 patient-months) compared to patients treated with CCPD (one episode/11.5 patient-months, p < 0.05). The spectrum of organisms causing infection was similar in both groups of patients. The study suggests that peritonitis and exit-site infections are significantly less common in patients treated with CAPD with the UltraBag system than in patients treated with CCPD.

To further study the effect of pulse oral calcitriol on the level of intact parathyroid hormone (iPTH), we have studied the response of 43 patients treated with 5.0 mcg calcitriol bi-weekly for one year. Mean iPTH decreased from 603 pg/mL +/- 262 (+/- SD) to 222 pg/mL +/- 185 (p < 0.001). Thirty-six patients responded showing a decrease in iPTH from baseline; 7 patients showed no decrease in iPTH. Transient hypercalcemia (calcium > 10.5 mg/dL) was noted in 6 patients of the responder group which corrected with temporary discontinuation of pulse therapy. Pulse oral calcitriol is an effective therapy to decrease elevated iPTH levels in continuous ambulatory peritoneal dialysis (CAPD) patients with hyperparathyroidism.

There has been a gradual increase in the number of diabetic and elderly patients maintained on continuous ambulatory peritoneal dialysis (CAPD) replacement therapy. Eighty randomly selected patients were studied over two years. Weekly normalized urea clearance (KT/Vurea), weekly creatinine clearance/1.73 m2 body surface area (BSA) (Ccr), and protein catabolic rate (PCR) were measured. Selected clinical outcome criteria were assessed. Weekly KT/Vurea was correlated with weekly Ccr (r = 0.538, p < 0.001), and weekly KT/Vurea was correlated with PCR (r = 0.393, p < 0.001). Patients were then stratified according to presence or absence of diabetes mellitus and age > 60 or < or = 60 years. Diabetic and nondiabetic patients had similar weekly KT/Vurea, weekly Ccr, PCR, serum albumin levels, weekly erythropoietin (EPO) requirements, peritonitis rates, and CAPD-related hospitalization rates. The total hospitalization rates, however, were higher in diabetic patients. Elderly and younger patients had similar weekly KT/Vurea, weekly Ccr, PCR, serum albumin levels, and weekly EPO requirements. Elderly patients, however, had higher peritonitis rates and higher total and CAPD-related hospitalization rates.

Hyperparathyroidism remains a cause of significant morbidity in dialysis patients. We studied pulse oral calcitriol, 5.0 micrograms biweekly to control hyperparathyroidism in 12 continuous ambulatory peritoneal dialysis (CAPD) patients. Parathyroid hormone (PTH) levels fell, while calcium and phosphorus levels remained in good control. Pulse oral calcitriol is an effective therapy for hyperparathyroidism in CAPD patients.

The optimal way to objectively measure the adequacy of continuous ambulatory peritoneal dialysis (CAPD) therapy remains controversial. It has been suggested that one-third or more of all CAPD patients are presently receiving "inadequate dialysis" when dialysis prescriptions are not carefully calculated. To better define the therapy being delivered in a large, freestanding CAPD center, weekly KT/V urea and creatinine clearance per 1.73 m2 body surface area were measured in 56 of 180 patients randomly selected from our unit in whom dialysis prescriptions were arbitrarily determined by nurses and physicians. In addition, protein catabolic rates and selected clinical outcome criteria were assessed. Weekly KT/V urea correlated with weekly creatinine clearance (r = 0.50) as well as with the protein catabolic rate (r = 0.45). Patients were arbitrarily divided into three groups based on KT/V urea measurements. Thirty percent of the patients had weekly KT/Vs < or = 1.4, 41% had KT/Vs between 1.5 and 1.8, and 29% had weekly KT/Vs > or = 1.9. Significant differences were not noted in hospitalization rates, erythropoietin doses, or serum albumin concentrations in patients with KT/Vs < or = 1.4 and in patients with KT/Vs > or = 1.9. Peritonitis rates were highest in the patients with KT/V > or = 1.9. Therefore, in patients randomly selected from our large CAPD center, 30% of the patients had weekly KT/V urea measurements < or = 1.4. The clinical significance of this finding remains uncertain.