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There is a paucity of data on the prognosis for patients returning to peritoneal dialysis (PD) after a failed transplant. PD has an advantage over hemodialysis in preserving residual renal function, which is associated with better outcomes. We have reviewed the electronic charts of patients on PD in a tertiary academic hospital for the last 8 years. We have compared technique survival, peritonitis-free survival, and residual diuresis in two groups: patients with graft failure which returned to PD (PD-KTx, N = 18) and patients starting PD for other causes (PD-not KTx, N = 163). The median follow-up was similar between groups [42(16,71) in PD-not KTx vs. 48(22,90) months in PD-KTx, p = 0.293]. Kaplan–Meier survival comparing PD-KTx and PD-not KTx showed no difference in technique survival (p = 0.196), and peritonitis-free survival (log-rank 0.238), which were confirmed in a fully adjusted Cox regression. Diuresis at baseline and at the end of the first year was similar between groups (p = 0.799 and p = 0.354, respectively). Six out of 18 patients from the PD-KTx group had the immunosuppression maintained and none of those had peritonitis. The reduction of diuresis across the first year of PD was significant for all patients, except for those on continued immunosuppressive therapy. PD is a worthy dialysis alternative after a failed kidney transplant, providing similar outcomes when compared to patients who started PD for other reasons.

Hypokalemia is a well-described electrolyte disturbance in patients on peritoneal dialysis (PD). Hyperkalemia, however, is still overlooked, although it also represents a risk factor for mortality. Angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (ACE/ARB), diuretics, and proton pump inhibitor (PPI) can interfere with potassium levels in these patients. This is a retrospective study that evaluated monthly serum potassium in a 5-year period. Serum potassium disturbances were evaluated as time-average and number of hypo- and hyperkalemia episodes per patient. Prescribed medication such as ACE/ARB, diuretics, and omeprazole were recorded. We evaluated 2025 potassium measurements obtained from 146 patients on PD. Serum potassium ranged from 2.5 to 8.3 mEq/L with an average of 4.72 ± 0.74 mEq/L. Hypokalemia was found in 59 measurements (2.9%) obtained from 35 patients (23.9%) whereas hyperkalemia was demonstrated in 269 (13.3%) measurements obtained from 74 patients (50.7%). Hypokalemia was associated with low albumin (p = 0.022), and omeprazole use (p = 0.024). Black race was a protector factor (p = 0.031). Omeprazole-associated hypokalemia was seen only in non-anuric patients and remained an independent risk factor even after adjustments. Patients who had hyperkalemia were more likely to be anuric (p = 0.001) and in use of furosemide (p = 0.0001). Hyperkalemia and hypokalemia are very frequent in patients on PD and should be closely monitored. Interventional studies should address the impact of discontinuing omeprazole in the levels of potassium.

Hyperuricemia is common among patients with chronic kidney disease (CKD). In the general population, hyperuricemia is associated with secondary hyperparathyroidism (SHPT), in a mechanism that involves vitamin D metabolism. Data for patients with CKD, however, are scarce. We aimed to evaluate the relationship between hyperuricemia and mineral and bone metabolism, particularly hyperparathyroidism.This is a retrospective study that included 922 adult patients with stages 3, 4, or 5 CKD, not on dialysis. Clinical, demographic, and biochemical data were collected from charts and included uric acid, parathyroid hormone (PTH), 25(OH)-vitamin D, calcium, phosphate, renal function (estimated glomerular filtration rate-eGFR), and medications such as allopurinol, furosemide, and cholecalciferol. SHPT was defined as PTH 65 pg/ml.Our patients were mostly Caucasian women, with a mean age of 64 ± 16 years. SHPT and hyperuricemia were observed in 70% and 62.4% of patients, respectively. Patients with SHPT presented higher levels of uric acid (7.2 ± 1.8 vs. 6.6 ± 1.7 mg/dL, p = 0.0001) and a higher frequency of hyperuricemia (66% vs. 33%, p = 0.0001). Patients with hyperuricemia were mostly female, with lower eGFR, higher phosphate, and higher PTH. The risk of hypovitaminosis D was higher among patients with SHPT (69.7% vs. 53.1%, p = 0.0001). Hyperuricemia remained independently associated with hyperparathyroidism, (p = 0.033) even after adjustments for eGFR, calcium, phosphate, hypovitaminosis D, and use of allopurinol, calcitriol, furosemide, and cholecalciferol.Hyperuricemia seems to be a contributing factor for SHPT in patients with CKD. The mechanisms behind this finding have yet to be elucidated.

There is a paucity of data on the prognosis for patients returning to peritoneal dialysis (PD) after a failed transplant. PD has an advantage over hemodialysis in preserving residual renal function, which is associated with better outcomes.We have reviewed the electronic charts of patients on PD in a tertiary academic hospital for the last 8 years. We have compared technique survival, peritonitis-free survival, and residual diuresis in two groups: patients with graft failure which returned to PD (PD-KTx, N = 18) and patients starting PD for other causes (PD-not KTx, N = 163).The median follow-up was similar between groups [42(16,71) in PD-not KTx vs. 48(22,90) months in PD-KTx, p = 0.293]. Kaplan-Meier survival comparing PD-KTx and PD-not KTx showed no difference in technique survival (p = 0.196), and peritonitis-free survival (log-rank 0.238), which were confirmed in a fully adjusted Cox regression. Diuresis at baseline and at the end of the first year was similar between groups (p = 0.799 and p = 0.354, respectively). Six out of 18 patients from the PD-KTx group had the immunosuppression maintained and none of those had peritonitis. The reduction of diuresis across the first year of PD was significant for all patients, except for those on continued immunosuppressive therapy.PD is a worthy dialysis alternative after a failed kidney transplant, providing similar outcomes when compared to patients who started PD for other reasons.

Bone biopsy defines classical diseases that constitute the renal osteodystrophy. There is a recent concern regarding other histological findings that are not appreciated by using the turnover, mineralization, and volume (TMV) classification. Iron (Fe) overload has been considered a new challenge and the real significance of the presence of this metal in bones is not completely elucidated. Therefore, the main goal of the current study was to not only to identify bone Fe, but also correlate its presence with demographic, and biochemical characteristics. This is a cross-sectional analysis of bone biopsies performed in 604 patients on dialysis from 2010 to 2014 in a tertiary academic Hospital. Histomorphometric findings revealed the presence of Fe in 29.1%. Fe was associated with higher levels of serum ferritin and serum calcium. No TMV status was related to Fe bone overload. Our study has highlighted that the presence of Fe in one-third of bone samples has unknown clinical significance. The lack of other contemporary bone biopsy study reporting Fe prevents us from comparison. The findings presented here should be specifically addressed in a future research and will require attention prior to implementation of any clinical guideline. If any proposed treatment, however, would change the bone Fe-related morbidity is undetermined.

As the world's population ages, the incidence of chronic kidney disease (CKD) is growing. There is ongoing debate regarding whether high levels of parathyroid hormone (PTH) would be more common in elderly than young patients, and which factors are driven the risk of secondary hyperparathyroidism (SHPT), independent of renal function.Elderly patients (age ≥ 65 years, N = 518) were compared to a 1:1 sex- and estimated glomerular filtration rate (eGFR)-matched sample of young patients (age 65 years), in a cross-sectional analysis. Demographic, biochemical and drug prescription data were collected from electronic charts. The main outcome measure was the prevalence of SHPT, defined as PTH 65 pg/mL.Elderly patients presented higher serum calcium and PTH levels and lower serum phosphate, and were taking more diuretics than young patients. SHPT was more frequent among elderly patients (49.4 vs. 38.6%, p = 0.005), and it was associated with lower eGFR, low levels of 25(OH) vitamin D and with furosemide therapy, while thiazide use was a protector factor. Elderly patients with 25(OH) vitamin D 40 ng/mL were protected against SHPT. The Ca/PTH ratio was lower in elderly than in young patients [0.15 (0.10, 0.20) vs. 0.16 (0.11, 0.23), respectively, p = 0.003].CKD elderly patients have higher risk of SHPT than young, which cannot be explained solely by renal function. Besides low levels of vitamin D, furosemide therapy and a distinct relationship between calcium and PTH are possible factors contributing to SHPT. Whether this is a result of renal resistance to PTH or an altered set point to calcium deserves further investigation.

The incidence of obesity is increasing both in the general population and in incident dialysis patients. While there is evidence that being overweight is associated with good outcomes in hemodialysis, the evidence in peritoneal dialysis (PD) patients is not very clear. We studied a modern cohort of PD patients to examine outcomes in large patients.Forty-three patients who started PD, who weighed more than 90 kg at dialysis initiation, between January/2000 and June/2010 were matched with 43 control patients who weighed less than 90 kg. Detailed review of the charts was undertaken.The mean weight and body mass index of the wt90 kg group were 69.3 ± 11.3 kg and 25.0 ± 3.9 kg/m(2). The number of peritonitis episodes per year was 0.33 ± 0.6 (wt90 kg) and 0.82 ± 1.7 (wt ≥ 90 kg) (p = 0.26). The median time to first peritonitis showed a trend toward earlier peritonitis in larger patients [9.5 (4.3, 27) months in wt ≥ 90 kg, 19.1(7.9, 30.8) months in wt90 kg] but did not reach statistical significance (p = 0.12). Surprisingly, hernias and leaks were more common in the weight90 kg group (44 vs. 18.6 % p = 0.02). There was no difference in total number of hospitalizations or the number of days hospitalized. Kaplan-Meier analysis of survival on PD showed no differences between the two groups (logrank p = 0.99). Cox regression analysis using age, race, cause of ESRD due to diabetes and Charlson comorbidity index as the covariates did not show weight to be associated with survival on PD.Large patients tend to do just as well on PD, with survival on PD being no different compared to individuals with lower weight and body mass index.

Sclerostin, secreted by osteocytes, plays a key role in antagonizing bone formation. Recent studies, which seldom include chronic kidney disease (CKD) patients, have reported on the association of sclerostin and mortality, with contradictory results. The assay-linked variability may contribute to these discrepant results. We have compared sclerostin results obtained with two assays (TECO and Biomedica) in a cohort of 91 CKD patients undergoing hemodialysis. We found a strong correlation (r = 0.870, p

Hyperleptinemia and metabolic acidosis (MA) are frequently observed in patients on hemodialysis (HD). While the role of leptin in patients on HD is not completely understood, HD only partially corrects MA. Both leptin and acidosis have effect on bone disease. The goal of the present study was to evaluate the effects of MA correction on chronic kidney disease–mineral and bone disorder laboratory parameters and leptin levels. Forty-eight patients on HD, aged 43 ± 19 years, were prospectively studied. Individual adjustments in the bicarbonate dialysate concentration were made to maintain pre-dialysis concentration ≥22 mEq/l. Blood gas analysis was done monthly for 4 months (M1–M4). From M0 to M4, serum albumin increased (from 3.5 ± 0.3 to 4.0 ± 0.3 g/l, p

The optimal target for glycated hemoglobin (HbA1c) has not been well defined in peritoneal dialysis (PD) patients with diabetes mellitus.The objective of our study was to examine the predictive value of predialysis and time-averaged follow-up HbA1c values on technique and patient survival in diabetic PD patients treated in the Toronto General Hospital Home Peritoneal Dialysis Unit, between January 1, 2003 and December 31, 2008 with a median follow-up period of 30±23 months.Ninety-one patients (mean age 64±13 years-old) were included in this retrospective study. Patients were followed between 3 and 91 months (mean duration 30±23 months). During this period, 40 patients died. We found no statistically significant correlation between baseline predialysis HbA1c values and technique and patient survival. Time-averaged follow-up HbA1c in increments6.5%, 6.5-8%, and8% showed no significant survival difference among groups.There was no significant correlation of baseline and time-averaged follow-up HbA1c values with patient and PD technique survival.

Intradialytic fluid redistribution may cause hypotension. Short daily hemodialysis (SDH) is a technique that increases frequency, potentially reducing the hypotension risk and allowing better ultrafiltration tolerance. Previous studies on conventional hemodialysis (CHD) indicate that fluid loss during dialysis occurs mainly from the legs [1, 2], maintaining the central blood volume. Whether the fluid loss from the legs is associated with hypotension symptoms in patients on SDH is unknown. We therefore performed a cross-sectional study to compare CHD and SDH regarding segmental fluid removal and its association with hypotensive symptoms, by using bioimpedance analysis (BIA). BIA techniques enable assessment of extra and intracellular water and currently appears to be the most practical method for assessing fluid status in dialysis patients [3]. Thirty-five patients on CHD and 15 on SDH had segmental BIA (InBody10 Analyzer ) done preand post-midweek dialysis. Baseline characteristics were similar between CHD and SDH (for age, dialysis vintage, blood pressure, absence of diabetes, and cardiac congestive failure). For both dialysis techniques, from preto post-dialysis, there was a reduction in the extracellular water (ECW) for each of the segments (leg, arm, and trunk), total body water (TBW), and ECW/TBW (p \ 0.05). The delta of legs of ECW was lower in SDH than in CHD [-3.3 % (-4.8, -0.7) vs. -5.4 % (-7.3, -2.4), p = 0.009] (Fig. 1). The relation ECW leg/trunk was lower in SDH than in CHD. Hypotensive symptoms (hypo?) were observed in six patients on SDH (37.5 %) and six patients on CHD (17.1 %). As shown in Table 1, hemoglobin was lower in CHD hypo? group; Within SDH group, patients who had hypotensive symptoms presented lower ECW leg/trunk at baseline and post-dialysis. From preto post-dialysis, there was an increase in the relation ECW leg/trunk in both CHD and SDH, although reached significance only in SDH group. This increase in the ECW leg/trunk was lower in SDH (hypo? group, p = 0.0017). As UF rate was high in SDH group, hypotensive symptoms could be observed. This scenario gave us a unique opportunity to test whether leg fluid removal would be associated with hypotensive symptoms in SDH, which we have demonstrated. In conclusion, the distribution of fluids from the legs to the trunk and the velocity of refilling