Search

Background: The 2006 Kidney Disease Outcomes Quality Initiative recommended a minimum total Kt/V of 1.7, eliminated creatinine clearance (Ccr) as a target, and recommended the use of ideal body weight to calculate Kt/V. We assessed these recommendations as predictors of outcomes in anuric peritoneal dialysis patients., Study Design: Retrospective observational study using administrative data., Setting & Participants: 1,432 peritoneal dialysis patients with anuria from January 1, 1994, to January 31, 2005, in a national sample (1,428 with Kt/V, 1,416 with Ccr)., Predictors: Kt/V and Ccr at anuria; Kt/V based on actual body weight and ideal body weight., Outcomes & Measurements: Association of dialysis adequacy with mortality and time to first hospitalization after anuria assessed by using accelerated failure time models., Results: 293 anuric patients had Kt/V less than 1.7, 366 had Kt/V of 1.7 to 2.0, and 769 had Kt/V greater than 2.0, using actual body weight for calculation. In unadjusted analyses, Kt/V calculated using actual body weight both less than 1.7 (-41.3%; 95% confidence interval [CI], -55.5 to -22.6) and 1.7 to 2.0 (-26.1%; 95% CI, -42.6 to -4.6) were associated with shorter time to mortality. Kt/V calculated using actual body weight less than 1.7 was associated with shorter time to hospitalization (-38.1%; 95% CI, -50.0 to -23.4), but Kt/V calculated using actual body weight of 1.7 to 2.0 was not a significant predictor (-3.3%; 95% CI, -21.1 to 18.6). After adjustment, Kt/V calculated using actual body weight less than 1.7 remained associated with mortality (-25.3%; 95% CI, -41.1 to -4.8) and hospitalization (-33.4%; 95% CI, -47.1 to -16.0). Ccr did not predict mortality. In unadjusted analysis, Ccr was not associated with hospitalization, but after adjustment, Ccr less than 50 L/wk/1.73 m(2) was significantly associated with shorter time to hospitalization (-19.9%; 95% CI, -35.0 to -1.3). Kt/V using ideal body weight was not a significant predictor in adjusted models., Limitations: This study was nonrandomized, with few malnourished patients. In addition, there is a potential for informative censoring for transfer to hemodialysis therapy before anuria., Conclusions: Kt/V calculated using actual body weight less than 1.7 in anuric peritoneal dialysis patients is associated with increased mortality and hospitalization. Use of ideal body weight to calculate Kt/V weakened the associations with outcomes and therefore cannot be recommended.

Depression is the most commonly encountered psychological problem in patients with end-stage renal disease (ESRD). Depression has recently been shown to significantly impact on the morbidity and mortality of patients undergoing therapy for ESRD. The present study was designed as a pilot study to evaluate the feasibility of screening a large cohort of patients maintained on chronic peritoneal dialysis (CPD) for depression and then pharmacologically treating those patients assessed to have clinical depression. One hundred thirty-six patients maintained on CPD in our CPD unit were screened for depression using the Beck Depression Inventory (BDI), a self-administered questionnaire. Patients with scores of 11 or greater were referred to a trained psychiatric interviewer for further evaluation to confirm the diagnosis of clinical depression and determine whether the patient was a candidate for antidepressant medication. Sixty-seven patients had BDI scores of 11 or greater, and 60 of these patients were asked to participate in further evaluation and possible therapy. Only 27 patients agreed to further study and were evaluated by a trained psychiatric interviewer for clinical depression. Twenty-three of these patients were assessed to have clinical depression, and 22 patients were eligible for antidepressant medication based on their scores on the Hamilton Depression Scale and psychiatric interview. Eleven patients completed a 12-week course of therapy with antidepressant medication, and their BDI scores decreased from a mean of 17.1 +/- 6.9 (SD) to a mean of 8.6 +/- 3.2. Seven patients were treated with sertraline, 2 patients with bupropion, and 2 patients with nefazodone. It is concluded that (1) depression is commonly present in patients maintained on CPD, (2) the BDI is a useful tool to use to screen for clinical depression, and (3) clinical depression is treatable with medication in this patient population.

The projected disproportionate increase in the number of elderly patients reaching end-stage renal disease constitutes a dramatic change in dialysis demographics. The nursing home or extended care facility (ECF) will become an increasingly important feature of care for both rehabilitation and long-term patient management. For continuous peritoneal dialysis (CPD), the ECF has been critically evaluated in only a single specialized, university-based, geriatric facility that included trained peritoneal dialysis nurses providing care. We have trained multiple ECF personnel in 10 community-based ECFs to provide all CPD-related therapy for 93 patients between November 1993 and December 1998, for a total of 289.3 patient-months. All ECFs have maintained their CPD program. Outcome measures, including hospitalization, mortality, technique failure, and peritonitis rates, show the success and feasibility of using community-based ECFs for CPD. The use of multiple ECFs for CPD appears to offer distinct advantages over solo structured ECF programs without jeopardizing outcomes. A highly structured CPD education program for ECF personnel by nephrology staff is manageable and appears critical for the success of maintaining CPD in the ECF.

The incidence and prevalence of end-stage renal disease (ESRD), particularly in the elderly population, have continued to increase in the United States. It is estimated that 10% to 20% of the elderly patients with ESRD have potentially remediable renal vascular disease. The purpose of the present study is to examine the results of renal artery revascularization in 20 patients aged older than 55 years with chronic renal failure (serum creatinine level >2 mg/dL) with proximal renal artery stenosis (RAS) diagnosed by magnetic resonance angiography (MRA) who underwent surgical or percutaneous revascularization. Patients were followed up closely in the postrevascularization period; renal function was monitored and potential complications of the procedure were carefully noted. Four of the 20 patients developed serious complications, including 3 patients with clinically significant atheroembolic disease and 1 patient with renal artery dissection. Seven patients developed greater than 5% eosinophilia. Five of the 20 patients had a deterioration in renal function 3 to 6 months after the procedure, and only 5 patients had a reduction in serum creatinine concentration 3 to 6 months after the procedure. The present study suggests that in elderly patients with chronic renal failure and proximal RAS, revascularization of renal vessels is associated with a high complication rate, and improvement in renal function occurs in only 25% of the patients. Whether revascularization can slow the rate of progression of renal failure remains uncertain and can only be answered by a large prospective trial.

The percentage of patients with end-stage renal disease (ESRD) maintained on chronic peritoneal dialysis (CPD) in the United States remains well less than the percentage in several other countries. Furthermore, there has recently been a decline in the percentage of patients with ESRD in the United States undergoing CPD. The reasons for this decline are uncertain, and investigators have implicated problems with the kinetics of peritoneal dialysis, peritonitis and exit-site infections, and psychosocial stresses imposed by the therapy. Few studies, however, have considered the role of the dialysis facility itself and patient perceptions of the facility as contributing to problems with the long-term acceptance of CPD. This study is designed to examine patients' perceptions of the organization and structure of the peritoneal dialysis facility and their interactions with the facility, focusing attention on areas of patient satisfaction and dissatisfaction with the facility. The study was conducted in a large, freestanding peritoneal dialysis program in an urban area that currently treats 140 patients undergoing CPD. Thirty patients were randomly selected to participate in the present study. A structured interview that included open-ended questions was administered and tape-recorded by a trained interviewer not affiliated with the dialysis unit. Patient responses were then reviewed by two investigators, and a taxonomy of patient satisfaction and dissatisfaction was developed, using a modification of the classification proposed by Concato and Feinstein. Patient responses were then categorized according to the taxonomy. The most frequently cited areas of patient satisfaction included the amount of information and instruction provided by the staff (n = 30), personal atmosphere of the facility (n = 30), efficiency of delivery of the dialysis supplies (n = 23), and availability of the primary nurse (n = 18). The importance of the nurse-patient interaction was emphasized by all 30 patients, whereas the physician-patient interaction was cited by only 14 patients. The most frequently cited area of dissatisfaction noted by all 30 patients concerned the dialysis regimen itself. The present study focuses attention on patient perceptions of their CPD facility, identifying areas of satisfaction and dissatisfaction. The analysis is important not only in providing a framework for CPD facilities with which to review their own interactions with CPD patients, but also for identifying those areas that require attention to maintain the long-term viability of CPD therapy.

Recent evidence suggested that noncompliance (NC) with continuous ambulatory peritoneal dialysis (CAPD) exchanges may be more common in US than in Canadian dialysis centers. This issue was investigated using a questionnaire-based method in 656 CAPD patients at 14 centers in the United States and Canada. NC was defined as missing more than one exchange per week or more than two exchanges per month. Patients were ensured of the confidentiality of their individual results. Mean patient age was 56 +/- 16 years, 52% were women, and 39% had diabetes. The overall admitted rate of NC was 13%, with a rate of 18% in the United States and 7% in Canada (P < 0.001). NC was more common in younger patients (P < 0.0001), those without diabetes (P < 0.001), and employed patients (P < 0.05). It was also more common in black and Hispanic than in Asian and white patients (P < 0.001). NC was more common in patients prescribed more than four exchanges daily (P < 0.0001) but was not affected by dwell volume. On multiple regression analysis, the independent predictors of NC, in order of importance, were being prescribed more than four exchanges per day, black race, being employed, younger age, and not having diabetes. Being treated in a US unit did not quite achieve significance as a multivariate independent predictor. These findings suggest that NC is not uncommon in CAPD patients and is more frequent in US than in Canadian patients. However, country of residence is less powerful as a predictor of NC than a variety of other demographic and prescription factors.

Paradoxical embolism is an uncommon but increasingly reported cause of arterial embolic events. Involvement of the kidney is rarely reported. Autopsy studies suggest, however, that embolic renal infarction is underdiagnosed antemortem. We report a case of bilateral, main renal artery occlusion and acute renal failure secondary to paradoxical embolism. Clinical and laboratory data at presentation were not suggestive of renal infarction. Support for the diagnosis of paradoxical embolism, which most commonly occurs across a patent foramen ovale, was made by contrast echocardiography, which provides a sensitive method for detecting right-to-left intracardiac shunts. The often subtle presentation of renal infarction suggests patients with peripheral or central arterial embolic events should be carefully observed for occult renal involvement. Contrast echocardiography should be performed when renal infarction occurs without a clear embolic source to evaluate for paradoxical embolism.

The incidence and prevalence of end-stage renal disease (ESRD) continues to increase, especially in the elderly population. The role of renovascular disease in contributing to ESRD is still not well defined. The objective of this study was to determine the utility of gadolinium (Gd)-enhanced magnetic resonance angiography (MRA) in evaluating elderly patients with renal insufficiency for renal artery stenosis (RAS). A 7-month prospective study conducted in a tertiary referral center evaluated 40 consecutive patients with progressive renal insufficiency (18 men and 22 women; mean age, 70 +/- 5.6 [standard deviation] years) and high clinical suspicion for renovascular disease with Gd-enhanced MRA. Digital subtraction angiography (DSA) was obtained in only those patients with significant RAS detected by MRA. Twelve patients had significant RAS. Six of these patients had percutaneous transluminal renal angioplasty (PTRA), five patients had renal artery bypass surgery, and one patient had a stent placed after PTRA. Seventy-eight renal arteries were satisfactorily evaluated by MRA. Twenty-two renal arteries were evaluated by both MRA and DSA. Of the 12 significant stenoses detected by the MRA, 11 were confirmed by DSA and 1 was confirmed at the time of surgical revascularization. It is concluded that Gd-enhanced MRA is a useful test for the evaluation of RAS in patients with compromised renal function.

Peritonitis remains the leading cause of patient dropout from continuous peritoneal dialysis (CPD) therapy. Few studies have compared patient morbidity, mortality, and outcome for patients undergoing CPD who develop gram-positive and gram-negative peritonitis. We retrospectively reviewed the charts of patients who developed either gram-positive or gram-negative peritonitis between January 1, 1993, and December 31, 1995. Three hundred seventy-five patients who developed 415 episodes of gram-positive and gram-negative peritonitis were maintained on CPD therapy during this time period. There was no difference in age, race, and sex between patients who developed gram-positive or gram-negative peritonitis. More patients with diabetes developed gram-negative peritonitis than gram-positive peritonitis (53% v 40%, respectively; P < 0.05). Coagulase-negative staphylococcal species accounted for 47% of all gram-positive episodes, whereas Klebsiella organisms, Escherichia coli, and Enterobacter organisms accounted for 63% of all gram-negative episodes. Significantly more patients who developed gram-positive peritonitis continued CPD therapy 2 weeks and 6 months after the onset of peritonitis than patients who developed gram-negative peritonitis (97% v 73%; P < 0.05 at 2 weeks and 81% v 58% at 6 months; P < 0.05, respectively). Nine percent of the patients who developed gram-positive peritonitis died within 6 months after the onset of peritonitis, whereas 21% of the patients who developed gram-negative peritonitis died (P < 0.05). Patients who developed gram-negative peritonitis were significantly more likely to require hospitalization than patients who developed gram-positive peritonitis (74% v 24%; P < 0.001). More patients with gram-negative peritonitis required peritoneal catheter removal than patients with gram-positive peritonitis (18% v 4%; P < 0.001). Thirty-two percent of the patients who developed gram-positive peritonitis re-developed an episode of peritonitis with the same organism compared with only 9% of the patients who developed gram-negative peritonitis. Furthermore, peritonitis recurrence with the same organism within 6 months after the initial episode was noted in 60% of the patients with peritonitis caused by Staphylococcus aureus compared with 24% of patients with peritonitis caused by other gram-positive organisms (P < 0.05). We conclude that the outcomes of gram-positive and gram-negative peritonitis are different. When rates of peritonitis are used to predict outcome, it appears that gram-positive and gram-negative peritonitis rates need to be examined separately.

Fungal peritonitis (FP) is a rare but serious complication of chronic peritoneal dialysis (CPD) therapy and is associated with high morbidity and CPD drop-out. Risk factors and management of FP remain controversial. We reviewed our experience with FP in an attempt to identify risk factors and to examine outcome in relation to treatment strategies. Between March 1984 and August 1994, 704 patients were maintained on CPD therapy in our unit. A total of 1,712 episodes of peritonitis were identified among these patients. Fungal peritonitis accounted for 55 (3.2%) of these episodes. The patients on CPD therapy who developed FP were similar to those who did not develop FP with regard to age, gender, underlying etiology for end-stage renal disease, and comorbid disease. Prior antibiotic use was noted in 87.3% of episodes of FP. The peritonitis rate in the patients who developed FP was one episode every 5.1 months compared with one episode every 9.9 patient-months in the CPD patients who did not develop this infection. Candida sp caused 74.5% of the episodes of FP. All patients were treated with antifungal drugs. In 85.5% of infections the Tenckhoff catheter was removed within 1 week of the diagnosis of FP; 31.9% of the patients who had the Tenckhoff catheter removed did not have the catheter replaced because of death or transfer to hemodialysis. In the patients who developed FP, 68.1% had the Tenckhoff catheter replaced; of these patients, 90.6% and 59.4% were on CPD therapy 1 and 6 months after catheter replacement, respectively. We conclude that risk factors identified in our population include peritonitis rate and prior antibiotic use. Fungal peritonitis is rare in our CPD population, and although it leads to significant CPD drop-out, it can be managed in many patients with antifungal therapy, early catheter removal, and temporary hemodialysis. Of the catheters replaced between 2 and 8 weeks after the diagnosis of FP, 91% functioned successfully, allowing continuation of CPD.

Polymicrobial peritonitis is a relatively uncommon, but potentially serious complication that develops in continuous ambulatory peritoneal dialysis (CAPD) patients. Its cause and optimal management remain controversial. The authors reviewed the frequency and natural history of polymicrobial peritonitis in 432 CAPD patients. Of 1,405 episodes of peritonitis, 80 were polymicrobial (6%). Patients with polymicrobial peritonitis were similar to all CAPD patients in age, gender, race, and underlying renal disease. Diabetes mellitus, human immunodeficiency virus (HIV) status, and clinically apparent gastrointestinal disease did not predisposes patients to polymicrobial peritonitis. Thirty days after the polymicrobial peritonitis, 64 patients remained on CAPD (80%), and at 180 days 48 patients continued CAPD. Prior exit-site infections were present in 12 patients (14%) with polymicrobial peritonitis. Only 22% of patients required catheter removal to treat the infection. We conclude that polymicrobial peritonitis accounts for 6% of the total episodes of peritonitis; diabetes, HIV infection, and underlying gastrointestinal disease are not more prevalent in patients with multiorganism infections. Most patients continue CAPD therapy at 30 and 180 days after the episode of polymicrobial peritonitis.

Ten patients with end-stage renal disease maintained on continuous ambulatory peritoneal dialysis therapy developed abdominal abscesses between 1982 and 1992. During this period, 537 patients cared for in our continuous ambulatory peritoneal dialysis unit developed 1,345 episodes of peritonitis. All abdominal abscesses were attributed to concomitant or antecedent peritonitis, suggesting that abscesses developed in 0.7% of peritonitis episodes. Abdominal pain, tenderness, fever, and nausea and vomiting were the most common presenting symptoms and signs. Radiographic findings that were helpful in establishing the diagnosis included abnormalities on computed tomography (CT) scanning, ultrasound, and Indium scanning. Seven patients developed intraperitoneal abscesses, two developed abdominal wall abscesses, and one developed both abdominal wall and intraperitoneal abscesses. Drainage of the abscesses was performed in all cases either surgically or percutaneously. Two patients died. The remaining eight patients have been maintained on hemodialysis therapy. The present data suggest that abdominal abscesses are uncommon complications of continuous ambulatory peritoneal dialysis-associated peritonitis. Prompt diagnosis by clinical criteria and radiographic techniques is important to permit appropriate drainage of the abscess cavity.

In a population of 214 patients on continuous ambulatory peritoneal dialysis (CAPD), 415 peritoneal infections occurred between 1980 and 1986. Fourteen of these infectious events were caused by Pseudomonas aeruginosa (3.4%). None of those patients with P aeruginosa peritonitis were cured by medical therapy alone. Peritoneal catheter removal was necessary to achieve resolution of the infection. Significant patient morbidity from Pseudomonas infection included loss of peritoneal space for further dialysis and abscess formation. Our data suggests that prompt catheter removal should be seriously considered for chronic ambulatory peritoneal dialysis patients who develop P aeruginosa peritonitis.

Renal biopsies were performed on 21 of 27 Melanesian patients presenting with significant proteinuria in Vanuatu from 1983 to 1985. All patients had more than 2 g of proteinuria per 24 hours or clinical evidence of the nephrotic syndrome. The average age of the patients who were biopsied was 31 years. Three of the 21 patients had evidence of active malaria at the time of presentation, and all of these patients had Plasmodium falciparum. Renal histopathology revealed that six patients (29%) had amyloidosis and five patients (24%) had mesangiocapillary glomerulonephritis (type 1). Of particular note was the fact that only one patient had membranous glomerulonephropathy and only one patient had minimal change nephrotic syndrome, the two most common lesions reported in nephrotic patients in Europe and the United States. Thus, the spectrum of renal histopathology in patients presenting in Vanuatu with significant proteinuria is very different from that seen in Western Countries.