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Background: Although caregivers allow peritoneal dialysis (PD) patients with disabilities the opportunity to perform PD, it is crucial to clarify the safety and effectiveness of assisted PD performed by caregivers compared to self-PD., Methods: PD patients from 22 PD centres in Thailand were prospectively followed in the Peritoneal Dialysis Outcomes and Practice Patterns Study during 2016-2017. Patients receiving assisted PD performed by caregivers were matched 1:1 with self-PD patients using propensity scores calculated by logistic regression. The associations between assisted PD and risk of mortality, peritonitis and permanent transfer to haemodialysis (HD) were assessed by multivariable competing risk regression., Results: Of 778 eligible patients, 447 (57%) required assisted PD performed by caregivers. Most of the caregivers were family members (98%), while the rest were non-family paid caregivers (2%). Patient factors associated with assisted PD were older age, female gender, lower educational level, cardiovascular comorbidities, diabetes, automated PD modality, poorer functional status and lower blood chemistries (albumin, creatinine, sodium, potassium and phosphate). After 1:1 matching, the baseline characteristics were adequately matched, and 269 patients in each group were analysed. Compared with self-PD, assisted PD was significantly associated with an increased risk of all-cause mortality (adjusted sub-hazard ratio: 2.15, 95% confidence interval: 1.24-3.74). There were no differences in the occurrences of peritonitis and permanent HD transfer between the groups., Conclusions: Assisted PD was required by more than half of Thai PD patients and was independently associated with a higher mortality risk. This may reflect causal effect or confounding by indication.

This study was designed as a pilot study to see whether electronic patient-reported outcome measures using computer adaptive technology (CAT) could be successfully implemented in clinics caring for chronic kidney disease (CKD) and peritoneal dialysis (PD) patients. The results demonstrate the feasibility of using CAT on an iPad to assess the symptom burden and health-related quality of life of both PD and CKD patients.

The development of peritoneal dialysis (PD) programmes in lower-resource countries is challenging. This article describes the learning points of establishing PD programmes in three countries in South Asia (Nepal, Sri Lanka and Pakistan). The key barriers identified were government support (financial), maintaining stable supply of PD fluids, lack of nephrologist and nurse expertise, nephrology community bias against PD, lack of nephrology trainee awareness and exposure to this modality. To overcome these barriers, a well-trained PD lead nephrologist (PD champion) is needed, who can advocate for this modality at government, professional and community levels. Ongoing educational programmes for doctors, nurses and patients are needed to sustain the PD programmes. Support from well-established PD centres and international organisations (International Society of Peritoneal Dialysis (ISPD), International Society of Nephrology (ISN), International Pediatric Nephrology Association (IPNA) are essential.

Background: Peritoneal dialysis (PD) is a viable option for renal replacement therapy in acute kidney injury (AKI), especially in challenging times during disasters and pandemics when resources are limited. While PD techniques are well described, there is uncertainty about how to determine the amount of PD to be prescribed toward a target dose. The aim of this study is to derive practical equations to assist with the prescription of PD for AKI., Methods: Using established physiological principles behind PD clearance and membrane transport, a primary determinant of dose delivery, equations were mathematically derived to estimate dialysate volume required to achieve a target dose of PD., Results: The main derivative equation is V D = (1.2 × std- Kt / V × TBW)/( t dwell + 4), where V D is the total dialysate volume per day, std- Kt / V is the desired weekly dose, TBW is the total body water, and t dwell is the dwell time. V D can be expressed in terms of dwell volume, v dwell , by V D = (0.3 × std- Kt / V × TBW) - (6 × v dwell ). Two further equations were derived which directly describe the mathematical relationship between t dwell and v dwell . A calculator is included as an Online Supplementary Material., Conclusions: The equations are intended as a practical tool to estimate solute clearances and guide prescription of continuous PD. The estimated dialysate volume required for any dose target can be calculated from cycle duration or dwell volume. However, the exact target dose of PD is uncertain and should be adjusted according to the clinical circumstances and response to treatment. The equations presented in this article facilitate the adjustment of PD prescription toward the targeted solute clearance.

Summary Statements: (1) Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings (1B) ., Guideline 2: Access and Fluid Delivery for Acute Pd in Adults: (2.1) Flexible peritoneal catheters should be used where resources and expertise exist (1B) (optimal) .(2.2) Rigid catheters and improvised catheters using nasogastric tubes and other cavity drainage catheters may be used in resource-poor environments where they may still be life-saving (1C) (minimum standard) .(2.3) We recommend catheters should be tunnelled to reduce peritonitis and peri-catheter leak (practice point) .(2.4) We recommend that the method of catheter implantation should be based on patient factors and locally available skills (1C) .(2.5) PD catheter implantation by appropriately trained nephrologists in patients without contraindications is safe and functional results equate to those inserted surgically (1B) .(2.6) Nephrologists should receive training and be permitted to insert PD catheters to ensure timely dialysis in the emergency setting (practice point). (2.7) We recommend, when available, percutaneous catheter insertion by a nephrologist should include assessment with ultrasonography (2C) .(2.8) Insertion of PD catheter should take place under complete aseptic conditions using sterile technique (practice point) .(2.9) We recommend the use of prophylactic antibiotics prior to PD catheter implantation (1B) .(2.10) A closed delivery system with a Y connection should be used (1A) (optimal) . In resource poor areas, spiking of bags and makeshift connections may be necessary and can be considered (minimum standard) .(2.11) The use of automated or manual PD exchanges are acceptable and this will be dependent on local availability and practices (practice point) ., Guideline 3: Peritoneal Dialysis Solutions for Acute Pd: (3.1) In patients who are critically ill, especially those with significant liver dysfunction and marked elevation of lactate levels, bicarbonate containing solutions should be used ( 1B) (optimal) . Where these solutions are not available, the use of lactate containing solutions is an alternative (practice point) (minimum standard) .(3.2) Commercially prepared solutions should be used (optimal) . However, where resources do not permit this, then locally prepared fluids may be life-saving and with careful observation of sterile preparation procedure, peritonitis rates are not increased (1C) (minimum standard) .(3.3) Once potassium levels in the serum fall below 4 mmol/L, potassium should be added to dialysate (using strict sterile technique to prevent infection) or alternatively oral or intravenous potassium should be given to maintain potassium levels at 4 mmol/L or above (1C) .(3.4) Potassium levels should be measured daily (optimal) . Where these facilities do not exist, we recommend that after 24 h of successful dialysis, one consider adding potassium chloride to achieve a concentration of 4 mmol/L in the dialysate (minimum standard) (practice point)., Guideline 4: Prescribing and Achieving Adequate Clearance in Acute Pd: (4.1) Targeting a weekly K t / V urea of 3.5 provides outcomes comparable to that of daily HD in critically ill patients; targeting higher doses does not improve outcomes (1B) . This dose may not be necessary for most patients with AKI and targeting a weekly K t / V of 2.2 has been shown to be equivalent to higher doses (1B) . Tidal automated PD (APD) using 25 L with 70% tidal volume per 24 h shows equivalent survival to continuous venovenous haemodiafiltration with an effluent dose of 23 mL/kg/h (1C) .(4.2) Cycle times should be dictated by the clinical circumstances. Short cycle times (1-2 h) are likely to more rapidly correct uraemia, hyperkalaemia, fluid overload and/or metabolic acidosis; however, they may be increased to 4-6 hourly once the above are controlled to reduce costs and facilitate clearance of larger sized solutes (2C) .(4.3) The concentration of dextrose should be increased and cycle time reduced to 2 hourly when fluid overload is evident. Once the patient is euvolemic, the dextrose concentration and cycle time should be adjusted to ensure a neutral fluid balance (1C) .(4.4) Where resources permit, creatinine, urea, potassium and bicarbonate levels should be measured daily; 24 h K t / V urea and creatinine clearance measurement is recommended to assess adequacy when clinically indicated (practice point) .(4.5) Interruption of dialysis should be considered once the patient is passing >1 L of urine/24 h and there is a spontaneous reduction in creatinine (practice point) ., The use of peritoneal dialysis (PD) to treat patients with acute kidney injury (AKI) has become more popular among clinicians following evidence of similar outcomes when compared with other extracorporeal therapies. Although it has been extensively used in low-resource environments for many years, there is now a renewed interest in the use of PD to manage patients with AKI (including patients in intensive care units) in higher income countries. Here we present the update of the International Society for Peritoneal Dialysis guidelines for PD in AKI. These guidelines extensively review the available literature and present updated recommendations regarding peritoneal access, dialysis solutions and prescription of dialysis with revised targets of solute clearance.

Heart failure (HF) is a major cause of morbidity and mortality. Extracorporeal (EC) therapy, including ultrafiltration (UF) and haemodialysis (HD), peritoneal dialysis (PD) and peritoneal ultrafiltration (PUF) are potential therapeutic options in diuretic-resistant states. This systematic review assessed outcomes of PD and compared the effects of PD to EC. A comprehensive search of major databases from 1966 to 2017 for studies utilising PD (or PUF) in diuretic-resistant HF was conducted, excluding studies involving patients with end-stage kidney disease. Data were extracted and combined using a random-effects model, expressed as odds ratio (OR). Thirty-one studies ( n = 902) were identified from 3195 citations. None were randomised trials. Survival was variable (0-100%) with a wide follow-up duration (36 h-10 years). With follow-up > 1 year, the overall mortality was 48.3%. Only four studies compared PD with EC. Survival was 42.1% with PD and 45.0% with EC; the pooled effect did not favour either (OR 0.80; 95% confidence interval (CI): 0.24-2.69; p = 0.710). Studies on PD in patients with HF reported several benefits. Left ventricular ejection fraction (LVEF) improved after PD (OR 3.76, 95%CI: 2.24-5.27; p < 0.001). Seven of nine studies saw LVEF increase by > 10%. Twenty-one studies reported the New York Heart Association status and 40-100% of the patients improved by ≥ 1 grade. Nine of 10 studies reported reductions in hospitalisation frequency and/or duration. When treated with PD, HF patients had fewer symptoms, lower hospital admissions and duration compared to diuretic therapy. However, there is inadequate evidence comparing PD versus UF or HD. Further studies comparing these modalities in diuretic-resistant HF should be conducted.

The goal of care of the peritoneal dialysis (PD) patient should be directed at adjusting therapy to maximize the patient's health-related quality of life (HRQOL). Incorporating the routine assessments of HRQOL into the care of PD patients is important and should serve as an essential marker of the adequacy of dialysis and help the dialysis staff design the optimal treatment regimen for each patient. HRQOL is best assessed with patient-reported outcome measures (PROMs). How best to incorporate these PROMs into the routine care of the PD patient is not clear in terms of the best instruments to use, frequency of measurements, patient acceptability, and how to translate these assessments into improvements in patient care. Nevertheless, incorporating routine assessments of HRQOL into the care of PD patients is essential if the dialysis team is to provide optimal care; it is an area that is receiving increasing attention and is ripe for further study and investigation.

Background: Current guidelines for the prescription of peritoneal dialysis dose rely on a single cut-off 'minimal' value of K t / V . To apply this in the clinic, this requires an accurate estimation of V , the volume of urea distribution that equates to the total body water (TBW). This analysis sought to determine the accuracy to which V can be estimated., Methods: A literature search was undertaken of studies comparing TBW estimation using two or three of the following methods: isotopic dilution (gold standard), anthropometric equations (e.g. Watson formula) and bioimpedance analysis. Studies of healthy and dialysis populations of all ages were included. Mean differences and 95% limits of agreement (LOA) were extracted and pooled., Results: In 44 studies (31 including dialysis subjects), the between-method population means were typically within 1-1.5 L of each other, although larger bias was seen when applying anthropometric equations to different racial groups. However, the 95% LOA for all comparisons were consistently wide, typically ranging ±12-18% of the TBW. For a typical individual whose TBW is 35 L with a measured K t / V of 1.7, this translates into a range of K t / V 1.4-2.05., Conclusions: There are limitations to the accuracy of estimation of V which call into question the validity of applying a single threshold K t / V value as indicative of adequate dialysis. This should be taken into account in guideline development such that if a target K t / V was deemed appropriate that this should be expressed as a range; alternatively single targets should be avoided and dialysis dose should be determined according to patient need.

Background: Little is known about the prevalence of functional impairment in peritoneal dialysis (PD) patients, its variation by country, and its association with mortality or transfer to hemodialysis., Methods: A prospective cohort study was conducted in PD patients from 7 countries in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) (2014 - 2017). Functional status (FS) was assessed by combining self-reports of 8 instrumental and 5 basic activities of daily living, using the Lawton-Brody and the Katz questionnaires. Summary FS scores, ranging from 1.25 (most dependent) to 13 (independent), were based on the patient's ability to perform each activity with or without assistance. Logistic regression was used to estimate the odds ratio (OR; 95% confidence interval [CI]) of a FS score < 11 comparing each country with the United States (US). Cox regression was used to estimate the hazard ratio (HR; 95% CI) for the effect of a low FS score on mortality and transfer to hemodialysis, adjusting for case mix., Results: Of 2,593 patients with complete data on FS, 48% were fully independent (FS = 13), 32% had a FS score 11 to < 13, 14% had a FS score 8 to < 11, and 6% had a FS score < 8. Relative to the US, low FS scores (< 11; more dependent) were more frequent in Thailand (OR = 10.48, 5.90 - 18.60) and the United Kingdom (UK) (OR = 3.29, 1.77 - 6.08), but similar in other PDOPPS countries. The FS score was inversely and monotonically associated with mortality but not with transfer to hemodialysis; the HR, comparing a FS score < 8 vs 13, was 4.01 (2.44 - 6.61) for mortality and 0.91 (0.58 - 1.43) for transfer to hemodialysis., Conclusion: Regional differences in FS scores observed across PDOPPS countries may have been partly due to differences in regional patient selection for PD. Functional impairment was associated with mortality but not with permanent transfer to hemodialysis., (Copyright © 2019 International Society for Peritoneal Dialysis.)

Background: Acute kidney injury (AKI) is common in low- and middle-income countries, and is associated with a high mortality. The high mortality rate is in large part due to the inability to perform dialysis in resource-limited settings. Due to significant cost advantages, peritoneal dialysis (PD) has been used to treat AKI in these settings. The costs, however, remain high when commercial solutions are used., Methods: This is a retrospective cohort study of the outcome, and of the peritonitis rates, of patients with AKI treated with either commercially manufactured PD solutions or locally-made PD solutions. A program to treat AKI with PD was started at Mbingo Baptist Hospital in Cameroon. Between May 2013 and January 2015, solutions and connection sets were provided by the Saving Young Lives Program. From January 2015 through March 2017, solutions were locally produced and available tubing was used., Results: Mortality in hospitalized AKI patients was 28% during the period when commercial solutions and tubing were utilized, and 33% when locally produced solutions and available tubing were utilized. In both groups, peritonitis occurred in 16% of treatment courses., Conclusions: Locally produced PD solutions, used with locally available tubing, were used to treat AKI with PD. The mortality and peritonitis rates were similar whether locally produced or commercial supplies were used., (Copyright © 2018 International Society for Peritoneal Dialysis.)

In December 2015, as part of the First African Dialysis Conference organized in Dakar, Senegal, 5 physicians from West African countries who have participated in the Saving Young Lives Program reviewed their experiences establishing peritoneal dialysis (PD) programs to treat patients with acute kidney injury (AKI). Thus far, nearly 200 patients have received PD treatment in these countries. The interaction and discussion amongst the participants at the meeting was meaningful and informative. The presentations highlighted the creativity, conviction, and determination of the physicians in overcoming the various barriers and challenges they encountered to establish PD/AKI programs. Hopefully, these successes and the increased awareness of the importance of early diagnosis and treatment of AKI will inspire much needed support from government, hospital, and international organizations., (Copyright © 2017 International Society for Peritoneal Dialysis.)

Background and Objectives: A large proportion of the patients on peritoneal dialysis (PD) in Brazil have low levels of education and family income. The present study assessed whether education level and family income are associated with baseline and longitudinal changes in health-related quality of life (HRQOL) scores during the first year of PD therapy., Methods: We evaluated 1624 incident patients from the Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) at baseline, and 486 of them after 12 months. The SF-36 was used to determine HRQOL and the Karnofsky index (KI), physical performance., Results: At baseline, patients received high KI scores compared with scores on the SF-36. The means of the mental and physical components at baseline and after 12 months were 39.9 ± 10.5 compared with 38.7 ± 11.7 and 41.8 ± 9.6 compared with 40.7 ± 9.8 respectively, which were not statistically different. A multivariate regression analysis showed that age, sex, diabetes, and cardiovascular disease were predictors of the mental component (respectively, β = 0.12, p < 0.001; β = 0.11, p < 0.001; β = -0.08, β = 0.007; and β = -0.07, p = 0.007) and that age, sex, diabetes, cardiovascular disease, hemoglobin, glucose, and creatinine were predictors of the physical component (respectively, β = -0.28, p < 0.001; β = 0.06, p = 0.009; β = -0.09, p = 0.002; β = -0.09, p = 0.001; β = 0.07, p = 0.004; β = -0.05, p = 0.040; and β = 0.05, p = 0.040). Education level and family income were not significantly associated with HRQOL (mental and physical components) in the multivariate regression., Conclusions: The results indicate that, as predictors, family income and education level have no impact on HRQOL, supporting the idea that socio-economic status should not be a barrier to the selection of PD as a treatment modality in Brazil.

Data on the burden of acute kidney injury (AKI) in resource-poor countries such as Tanzania are minimal because of a lack of nephrology services and an inability to recognize and diagnose AKI with any certainty. In the few published studies, high morbidity and mortality are reported. Improved nephrology care and dialysis may lower the mortality from AKI in these settings. Hemodialysis is expensive and technically challenging in resource-limited settings. The technical simplicity of peritoneal dialysis and the potential to reduce costs if consumables can be made locally, present an opportunity to establish cost-effective programs for managing AKI. Here, we document patient outcomes in a pilot peritoneal dialysis program established in 2009 at a referral hospital in Northern Tanzania.

Encapsulating peritoneal sclerosis (EPS) is a serious complication of long-term peritoneal dialysis (PD). The reported incidence varies between 0.5% and 4.4% and increases with length of time on PD. Very few data are available on the epidemiology of EPS in the United States. The aim of the present study was assess the incidence of EPS in a single center in New Haven, Connecticut. In a retrospective analysis of all patients maintained on PD for 5 or more years, clinical symptoms were documented, abdominal computed tomography (CT) findings were reviewed, and surgical and pathology findings were noted. Patients were tracked whether they remained on PD, transferred to hemodialysis (HD), underwent transplantation, or died. Among the 76 patients that met the inclusion criteria (mean dialysis duration: 81.5 ± 22 months), 14 (18%) developed clinical symptoms (persisting for 3 or more months) suggestive of EPS. Abdominal CT imaging was done in 38 patients; 25 had radiologic features consistent with EPS. At laparotomy, 6 of 7 patients had gross findings consistent with EPS. Eleven patients met the 2000 criteria of the International Society for Peritoneal Dialysis for a diagnosis of EPS; they had clinical features, plus either radiologic or histopathologic confirmation. In 3 patients with clinical symptoms, the radiologic or surgical findings did not support a diagnosis of EPS. Of the 11 patients meeting the EPS criteria, 1 remains on PD and is doing well, 2 were transferred to HD and are doing well, 2 died as a result of EPS complications, and 6 died of other causes. The present study suggests that, in patients maintained on PD for 5 or more years at our center, the incidence of EPS is 14%. Those findings suggest that EPS may be underrecognized in the United States and that a high index of suspicion is warranted in patients maintained on PD for 5 or more years.

Objective: To determine the contribution of vitamin C (Vit C) status in relation to hemoglobin (Hb) levels in patients on long-term peritoneal dialysis (PD)., Methods: 56 stable PD patients were evaluated in a cross-sectional survey. Plasma samples were collected for Vit C (analyzed by HPLC with electrochemical detection) and high-sensitivity C-reactive protein (hs-CRP) determinations. Clinical records were reviewed for Hb, transferrin saturation (TSAT), ferritin, erythropoietin (EPO) dose, and other clinical parameters. Dietary Vit C intake was evaluated by patient survey and from patient records. Total Vit C removed during PD treatment was measured in 24-hour dialysate collections., Results: Patients showed a highly skewed distribution of plasma Vit C levels, with 40% of patients below normal plasma Vit C levels (<30 μmol/L) and 9% at higher than normal levels (>80 μmol/L). Higher plasma Vit C levels were associated with higher Hb levels (Pearson r = 0.33, p < 0.004). No direct connection between Vit C levels and reported dietary intake could be established. In stepwise multiple regression, plasma Vit C remained significantly associated with Hb (p = 0.017) but there was no significant association with other variables (dialysis vintage, age, ferritin, TSAT, hs-CRP, residual renal function, and EPO dose). In 9 patients that were evaluated for Vit C in dialysate, plasma Vit C was positively associated (Spearman r = 0.85, p = 0.01) with the amount of Vit C removed during dialysis treatment., Conclusions: These data indicate that plasma Vit C is positively associated with higher Hb level. Vit C status could play a major role in helping PD patients to utilize iron for erythropoiesis and achieve a better Hb response during anemia management.

Background: Hemodialysis (HD) and peritoneal dialysis (PD) are both viable options for renal replacement therapy. Technique failure has been shown to be a major problem in PD therapy., Objective: To examine the relationship between center size and PD technique failure., Setting: ESRD Network #1 (NW1)., Design: Retrospective review of NW1 database., Patients and Methods: 5003 incident PD patients between 2001 and 2005 in 105 PD units were included. Patients were grouped into 2 based on center size: group A, patients in units with 25 patients. Outcome measures were analyzed for the first and second years of PD therapy. Patients were censored at transplantation, transfer to HD, or death., Outcome Measures: Technique failure and mortality reported as death in Standard Information Management Systems (SIMS) database (NW1 data system)., Results: Technique failure rates were significantly higher in group A for year 1 (odds ratio: 1.36, p = 0.005) and for year 2 (odds ratio: 1.35, p = 0.03). Mortality rates were not statistically different between the 2 groups., Conclusion: Technique failure was higher in units with 25 patients. There was no difference in mortality between the 2 groups. The majority of patients in NW1 receive care in small units.

Objective: Very few studies have addressed the relationship between number of peritoneal dialysis (PD) patients treated at a clinic (PD clinic size) and clinical outcomes. In a national prospective cohort study of incident PD patients (n = 236, from 26 clinics), we examined whether being treated at a larger PD clinic [>50 PD patients (n = 3 clinics) vs 50 patients was associated with fewer switches to hemodialysis (RH = 0.13, 95% CI 0.06 - 0.31) and fewer cardiovascular events (RH = 0.62, 95% CI 0.06 - 0.98). No associations of PD clinic size with cardiovascular or all-cause mortality were seen., Conclusion: PD patients treated at clinics with greater numbers of PD patients may have better outcomes in terms of technique failure and cardiovascular morbidity. PD clinic size may act as a proxy of greater PD experience, more focus on the modality, and better PD practices at the clinic, resulting in better outcomes.

Objective: Previous studies have shown that patients with end-stage renal disease (ESRD) treated with continuous peritoneal dialysis (CPD) have better preservation of endogenous renal function than patients treated with hemodialysis (HD). We wondered if this better preservation of endogenous renal function seen with CPD patients translates into the improved likelihood of recovery of endogenous renal function in those patients with potentially reversible causes of renal failure., Methods: To evaluate this question, we reviewed the records of all 1200 patients that completed CPD training at a large, freestanding peritoneal dialysis center in New Haven, Connecticut, between 1979 and 1999, and the records of all patients completing CPD training in New England between 1993 and 1998. In New Haven, about half the new patients with ESRD were started on CPD compared to only 15% in New England. We then compared the chances of recovery of renal function in these two cohorts of CPD patients to the chances of recovery of renal function in two groups of HD patients. The first group consisted of all patients that started on HD in New England between 1993 and 1998. The second group consisted of all patients that started HD in our HD unit in New Haven, Connecticut, between 1993 and 1999. The data on the New England patients were provided by the ESRD Network of New England. All patients entered into the present study had to have been on dialysis for a minimum of 3 months, as in the United States Renal Data System database, and had to have recovered sufficient renal function to be able to be maintained off dialysis for a minimum of 30 days., Results: 29 of 1,200 CPD patients (2.4%) trained in New Haven recovered sufficient renal function to permit the discontinuation of dialysis for a minimum of 30 days. In comparison, only 305 of 19,032 patients (1.6%) managed with HD in New England (p < 0.05 compared to New Haven CPD patients) and 3 of 430 patients (0.7%) in our HD center (p < 0.05 compared to New Haven CPD patients) recovered sufficient glomerular filtration rate (GFR) to allow the discontinuation of dialysis for at least 30 days. If only those CPD patients that initiated dialysis between 1993 and 1999 in New Haven were analyzed, 15 of 369 (4.1%) recovered sufficient GFR to allow discontinuation of dialysis for at least 30 days (p < 0.025 compared to both groups of HD patients). Of the 2,924 patients completing CPD training in New England, 60 (2.1%) recovered renal function; this percentage is not significantly different from the percent of HD patients in New England recovering renal function., Conclusion: Although the present study is a retrospective study and the actual criteria for selection of CPD and HD therapy are not controlled for, the data raise the question of whether there may be a therapeutic advantage to treating newly diagnosed ESRD patients, that have a potentially reversible cause of renal failure, with CPD.

Background: The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) has evidence- and opinion-based recommendations for weekly Kt/V(urea) and weekly total creatinine clearance (CC) in chronic peritoneal dialysis (CPD) patients. Using standard continuous ambulatory peritoneal dialysis technique, it is often difficult to achieve the suggested targets in anuric patients with large body mass. Thus, the use of automated peritoneal dialysis (APD) has been increasingly utilized to achieve adequate clearances. Automated dialysis is usually performed at night over an 8- to 10-hour period. The role of increases in dialysate volume and frequency of exchanges during this time period to achieve these target K/DOQI recommendations remains uncertain. We decided to study the effects of increasing the volume and number of exchanges in a fixed period of time in CPD patients., Methods: In the New Haven CAPD unit, 29 patients maintained on APD were considered eligible for the study and 11 agreed to participate. The patients were characterized according to standard peritoneal equilibration test criteria. The patients were placed into two groups: group 1 included high (H) and high-average (HA), and group 2 low-average (LA) transporters. The patients were dialyzed at night for 9 hours with standard cycling technique, using 2.5% Dianeal (Baxter Healthcare, Deerfield, Illinois, USA) solution, with a cycle volume of 2,500 mL, and a 2,000-mL daytime dwell. Three studies were done on each patient using a total dialysis volume of 9.5 L (3 cycles), 14.5 L (5 cycles), and 19.5 L (7 cycles). Daily Kpt/V(urea) and daily CCp (peritoneal) (L/day/1.73 m2) were obtained., Results: Six patients were H or HA (group 1) and 5 were LA transporters (group 2). For the group 1 patients, mean weight was 86.6 +/- 13.5 kg; Kpt/V(urea) was 1.68 +/- 0.21 using 9.5 L, 2.03 +/- 0.28 for 14.5 L (p < 0.05 compared to 10 L), and 2.28 +/- 0.28 with 19.5 L (p < 0.05 compared to 10 L and 15 L); mean weekly CCp was 45.43 +/- 7.63 L/1.73 m2 for 9.5 L (p < 0.05 compared to 14.5 L and 19.5 L), 51.17 +/- 7.07 with 14.5 L, and 54.67 +/- 10.08 for 19.5 L; ultrafiltration rates were not different in the three studies. For the group 2 patients, mean weight was 74.3 +/- 17.7 kg; mean weekly Kpt/V(urea) was 1.68 +/- 0.35 using 9.5 L, 2.10 +/- 0.42 for 14.5 L (p < 0.05 compared to 9.5 L), and 2.31 +/- 0.56 for 19.5 L (p < 0.05 compared to 9.5 L and 14.5 L); mean weekly CCp was 42.56 +/- 10.64 L/1.73 m2 for 9.5 L (p < 0.05 compared to 14.5 L and 19.5 L), 50.89 +/- 12.66 for 14.5 L, and 51.94 +/- 11.20 for 19.5 L; ultrafiltration was lower in the 9.5-L study than in the 14.5-L and 19.5-L studies, but was not different in the 14.5-L and 19.5-L studies., Conclusions: In both H/HA and LA transporters, Kpt/V(urea) and CCp rise significantly when the frequency of exchanges and total volume of dialysate are increased. Thus, the use of larger volumes of dialysate with cycling peritoneal dialysis may result in increased clearances of urea and creatinine.

Objectives: There has been increasing interest in understanding how patients with chronic renal failure choose between chronic peritoneal dialysis (CPD) and hemodialysis (HD) for renal replacement therapy. The purpose of the present study was to examine the influences and specific factors that patients identify as significant in choosing a specific dialysis modality for treatment of their end-stage renal disease (ESRD)., Patients and Design: 40 patients (20 CPD, 20 HD) who had started dialysis within the preceding 6 months were randomly selected to participate in the study. A structured interview was conducted with the patients, discussing and exploring what factors patients thought were important in helping them decide their treatment modality. The format of the interview was open-ended. Based on patients' comments, a taxonomy of the specific factors that influenced the patients' decisions was developed., Setting: The study was conducted in a freestanding CPD unit and two freestanding HD units., Results: All 20 CPD patients reported choosing their treatment modality; only 8 of the 20 HD patients reported having a choice of treatment modality. 18 of the 22 patients who participated in predialysis educational programs opted for CPD. 83% of the patients reported that their physician was important in influencing their treatment choice; however, the CPD patients relied more on written material and the opinions of their spouse/significant other or other family members in making their decisions. Issues of autonomy and control were important for 95% of patients choosing CPD. Both CPD and HD patients cited a variety of treatment-specific factors. The three most frequently cited reasons for choosing CPD were (1) flexibility of schedule (19 patients), (2) convenience of performing CPD in their own home (19 patients), and (3) the option of doing dialysis at night while sleeping (8 patients). The 8 HD patients who selected their treatment modality cited the desirability of having a planned schedule (7 patients) and letting nurses or other take care of them (5 patients)., Conclusions: The present study explored factors perceived by patients as being important in determining their choice of renal replacement therapy. A taxonomy of patient influences and concerns has been developed to provide caregivers with a framework to structure their educational strategies and assist patients with progressive renal failure in making an informed choice of therapeutic modality for their ESRD treatment.

Objectives: Sexual and erectile dysfunction (ED) have been reported to occur frequently in male patients with end-stage renal disease maintained on dialysis. Numerous etiologies for this ED have been suggested. Although a variety of therapies for the ED of the dialysis patient have been suggested, most clinicians indicate that patients report a poor response to therapy. Recently, sildenafil has been reported to be beneficial in treating patients with ED of both organic and psychogenic causes. The present study was designed to document the incidence of ED in male patients maintained on chronic peritoneal dialysis (CPD) and to determine the efficacy of prescribing sildenafil therapy to treat their ED., Methods: All male patients in our CPD unit were notified by letter of the availability of sildenafil as a treatment modality for ED. A sexuality/erectile dysfunction assessment was conducted in all male patients by their primary nephrologist. Patients who reported ED and who had no medical contraindication to sildenafil were offered this therapy. Those patients who were interested in this treatment were interviewed by a social worker, and patients were asked to complete the International Index of Erectile Function questionnaire. Sildenafil was prescribed at a starting dose of 25 mg and increased to a maximum of 100 mg during a 12-week study trial. Patients were re-evaluated 6 and 12 weeks after the start of therapy., Results: There were 68 male patients maintained on CPD at the time of the study. Mean age of all patients was 60.8 +/- 15.3 years and mean duration on PD was 32.6 +/- 25.6 months. Thirty-three patients had diabetes, 66 hypertension, 35 peripheral vascular disease, and 32 coronary artery disease. Thirty-two of 68 male patients in the CPD unit were assessed to have ED. Only 17 of the 32 patients expressed interest in pursuing sildenafil therapy. Two of these patients were excluded because they were receiving nitrate therapy. Of the 15 patients who agreed to take sildenafil, only 6 completed the 12-week study. Two of these patients responded to sildenafil., Conclusion: Erectile dysfunction is common in male patients maintained on CPD. Only about half of patients with ED in the present study were willing to consider sildenafil therapy to treat the ED and, of those who agreed to treatment, only a minority completed the 12-week trial; 2 of these 6 patients reported a satisfactory response.

Background: The Dialysis Outcomes Quality Initiative (DOQI) guidelines, published in 1997, emphasize the need for careful monitoring of iron stores and for provision of adequate iron replacement therapy to achieve target goals of hemoglobin concentration in end-stage renal disease (ESRD) patients, especially those treated with recombinant erythropoietin (rHuEPO). Intravenous iron dextran (IVID) therapy, which has long been used in hemodialysis patients, is increasingly being used in chronic peritoneal dialysis (CPD) patients. In 1997, we began using this form of iron therapy for our CPD patients. However, because considerable data exists to show a relationship between iron metabolism and acute infections, we questioned whether IVID infusion placed our patients at greater risk for peritonitis, the leading cause of death and patient drop-out from CPD therapy., Objective: To evaluate the relationship between iron and infection, we studied episodes of peritonitis in CPD patients who were infused with IVID., Design: In a retrospective study of adult CPD patients who received IVID during 1998, we investigated the occurrence of peritonitis episodes and the spectrum of causative organisms. Patients with a hemoglobin level of < 12.5 g/dL who also had a ferritin level < 100 ng/mL or a transferrin saturation level < 20% (or both) and who did not respond to oral iron therapy, were administered between 0.5 g and 1.0 g of IVID in an outpatient hospital setting. We calculated the expected and observed number of peritonitis episodes in these patients within 30, 60, and 90 days after infusion of IVID., Results: During the study period, 56 patients received 77 doses of IVID, with 14 patients requiring 2 or more infusions. Of the 77 doses, 71 were given as a 1-g bolus. The IVID was well tolerated by all patients. Within 90 days of IVID administration, 14 patients developed peritonitis: 6 episodes occurred within 30 days, 7 episodes occurred between 31 and 60 days, and 1 episode occurred between 61 and 90 days after the IVID dosing. The peritonitis rate for patients not receiving IVID was 1 episode per 13.7 patient-months. Taking this rate as the "expected" rate, the expected number of episodes of peritonitis for the study population was 5.6 episodes within 30 days, 11.2 episodes within 60 days, and 16.8 episodes within 90 days following IVID administration. The difference between the expected and observed rates of peritonitis in patients who were dosed with IVID was not statistically different. The spectrum of organisms seen in the peritonitis episodes in the study population was not significantly different from that seen in the peritonitis episodes in our CPD unit population., Conclusions: There is evidence that IVID infusion therapy can improve anemia and reduce rHuEPO requirements in CPD patients, usually without adverse reaction and without exposing patients to an increased risk of peritonitis. More research is needed in the area of potential increased risk of infection in ESRD patients who are (1) infused with large doses of IVID, and (2) iron-overloaded.

Objective: Long-term chronic peritoneal dialysis (CPD) therapy has been associated with alterations in peritoneal membrane structure and peritoneal macrophage function. We thus reviewed our experience with the development of peritonitis among patients maintained on CPD therapy for various time periods to determine if the spectrum of organisms, rates of peritonitis, and outcome changed with the duration of CPD therapy., Setting and Patients: Patients maintained on CPD therapy in our out-patient unit in New Haven, Connecticut., Design: Retrospective review of the charts of patients maintained on CPD therapy (HomeChoice Cycler or Ultrabag, Baxter, McGaw Park, IL, U.S.A.) between 1 January 1997 and 31 March 1998. These patients were divided into three groups: group 1, patients maintained on CPD therapy < or = 12 months; group 2, patients maintained on CPD therapy for 13-36 months; and group 3, patients maintained on CPD therapy for > or = 37 months., Results: The study included 256 patients: 101 patients in group 1, 110 patients in group 2, and 45 patients in group 3. All groups of patients were similar in age. There were significantly fewer Caucasians and fewer males in group 3 in comparison to groups 1 and 2. The incidence of diabetes mellitus, coronary artery disease, and peripheral vascular disease was significantly lower among patients in group 3 in comparison to groups 1 and 2. There were 155 episodes of peritonitis during the study period for an overall rate of 1 episode in 18.7 patient-months. The overall, gram-positive, and gram-negative rates of peritonitis were not significantly different among the patients in groups 1, 2, and 3. There were more episodes of Staphylococcus aureus peritonitis among patients in group 3 in comparison to group 2 (1 episode in 59.6 vs 1 episode in 280.2 patient-months, respectively). Two weeks after the development of peritonitis, 94.6% of the patients in group 3 continued CPD therapy, while 79.4% of the patients in group 1 continued CPD therapy (p < 0.05). No patient in group 3 transferred to hemodialysis, while 10.3% and 8.2% of the patients in groups 1 and 2 transferred to hemodialysis (p < 0.05). The death rate 2 weeks after the onset of peritonitis was 10.3%, 9.8%, and 5.4% in groups 1, 2, and 3, respectively (p = NS)., Conclusions: Despite the immunological and morphological changes that occur in the peritoneal cavity with increased time on CPD therapy, there was no difference in the overall, gram-positive, or gram-negative rates of peritonitis for patients maintained on CPD therapy for various time periods. Patients in group 3 continued CPD therapy more often than did patients in group 1. Patients in group 3 transferred to hemodialysis less often than did the remaining patients in the study period. The incidence of death was not significantly different for the three groups of patients.

Objective: To describe our experience with nosocomial continuous peritoneal dialysis (CPD)-associated peritonitis focusing on the incidence, possible risk factors, spectrum of organisms, and outcome., Design: Retrospective review of the medical records of our CPD patients admitted to an acute-care hospital between November, 1993 and December, 1994., Setting: University-associated acute-care hospitals in New Haven, Connecticut., Patients: One hundred and eighty-eight patients maintained on CPD therapy and admitted to an acute-care hospital., Results: Nineteen patients (5%) developing nosocomial peritonitis (NP) were identified from the 408 admissions occurring during the study period. Patients developing NP were older than the hospitalized CPD patients not developing NP (65.5 +/- 14.6 vs 58.4 +/- 14.7 years, p < 0.05). Comorbid diseases including diabetes, peripheral vascular disease, gastrointestinal disease, cardiovascular disease, and human immunodeficiency virus seropositivity were not more common in the patients developing NP. Patients developing NP were hospitalized significantly longer than the CPD patients not developing NP (39.5 +/- 46.5 days vs 12.7 +/- 12.4 days, p < 0.001). The mean serum albumin was lower in the NP patients than in the CPD patients not developing NP (2.35 +/- 0.52 g/dL vs 3.02 +/- 0.60 g/L, p < 0.001). Antecedent antibiotic use and performance of invasive procedures were noted in 89% and 68% of the patients developing NP, respectively. Staphylococcal species, enterococcal species, and gram-negative organisms accounted for 26%, 21%, and 53% of the episodes of NP, respectively. Furthermore, two strains of Enterococcus resistant to vancomycin were cultured. Eight patients developing NP expired, 8 patients continued CPD therapy, 2 patients transferred to hemodialysis, and one patient recovered renal function., Conclusion: We conclude that NP is uncommon. Increased age, increased length of hospital stay, and hypoalbuminemia may predispose patients to the development of NP. Further studies with case controls should help to clarify whether antecedent antibiotics or prior performance of invasive procedures predispose patients to the development of nosocomial peritonitis. The spectrum of organisms accounting for NP is different than the spectrum of organisms causing community-acquired CPD-associated peritonitis. Some of these organisms may be resistant to standard antibiotic therapies. Patients developing NP do poorly, with 42% expiring while being treated for NP.

Objective: The purpose of the study is to review our experience with patients over 80 years of age with end-stage renal disease (ESRD) treated with continuous ambulatory peritoneal dialysis (CAPD)., Design: The records of all patients over 80 years of age treated in our unit with CAPD since 1979 were reviewed., Setting: Out-patient CAPD facility., Patients: Eighteen patients over 80 years of age were identified and studied., Main Outcome Measures: The duration of CAPD therapy, duration of CAPD training, mortality rate, hospitalization rate, peritonitis rate, and family assessment were reviewed and analyzed., Results: The mean +/- SD duration of therapy was 20 +/- 17 months. Nine patients expired, 3 transferred to hemodialysis, 1 recovered renal function, and 5 remained on CAPD therapy. Peritonitis rates were 1.7 episodes/patient year. Of the organisms causing peritonitis, 56% were gram-positive bacteria. The average hospitalization rate was 13.9 days/patient year. The most frequent causes of hospitalization were peritonitis and cardiovascular disease., Conclusion: CAPD therapy is a reasonable therapeutic option for patients with end-stage renal disease over 80 years of age.

In 1989, a conference was held to discuss the current status of technique survival for patients treated with continuous ambulatory peritoneal dialysis (CAPD). Major reasons for patient drop-out from CAPD-peritonitis, inadequate dialysis, catheter-related problems and psychosocial factors-were reviewed, as were constructive techniques for dealing with these problems and areas for future investigation.