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The life qualities of end-stage renal disease (ESRD) patients rely largely on adequate dialysis, and a well-functioning vascular access is indispensable for high quality hemodialysis. Despite the advancement of surgical skills and the optimal maintenance of arteriovenous fistula (AVF), malfunction of AVF is still frequently encountered and has great impact on the life of ESRD patients. Several medical, mechanical and genetic prognostic factors are documented to affect the patency of AVF and arteriovenous graft (AVG). Heme oxygenase-1 (HO-1) is one of the genetic factors reported to play a role in cardiovascular disease and the patency of vascular access. Far infrared (FIR), a novel therapeutic modality, can not only conduct heat energy to AVF but also stimulate the non-thermal reactions mediated by HO-1. The use of FIR therapy significantly enhances the primary patency rate and maturation of AVF with fewer unfavorable adverse effects, and also achieves higher post-angioplasty patency rate for AVG. The only limitation in proving the effectiveness of FIR therapy in enhancing patency of AVF is that all the studies were conducted in Chinese people in Taiwan and thus, there is a lack of evidence and experience in people of other ethnicities.

Objectives: There is a lack of consensus on the risk factors for hernia formation, and the impact on peritoneal dialysis (PD) survival has seldom been studied., Methods: This was a population-based study and all collected data were retrieved from the National Health Insurance Research Database of Taiwan. Patients who commenced PD between January 1998 and December 2006 were screened for inclusion. Multiple logistic regression and Cox proportional hazards models were applied to estimate the predictors for hernia formation and determine the predictors of PD withdrawal., Results: A total of 6,928 PD patients were enrolled and followed until December 2009, with 631 hernia events and 391 hernioplasties being registered in 530 patients (7.7%). The incidence rate was 0.04 hernias/patient/year. Longer PD duration (per 1 month increase, hazard ratio (HR) 1.019) and history of mitral valve prolapse (MVP) (HR 1.584) were independent risk factors for hernia formation during PD, and female gender (HR 0.617) was a protective factor. On the other hand, there were 4,468 PD withdrawals, with cumulative incidence rates of 41% at 1 year, 66% at 3 years, and 82% at 5 years. Independent determinants for cumulative PD withdrawal included hernia formation during PD (HR 1.154), age (per 1 year increase, HR 1.014), larger dialysate volume (per 1 liter increase, HR 0.496), female gender (HR 0.763), heart failure (HR 1.092), hypertension (HR 1.207), myocardial infarction (HR 1.292), chronic obstructive pulmonary disease (COPD) (HR 1.227), cerebrovascular accident (CVA) (HR 1.364), and history of MVP (HR 0.712) CONCLUSIONS: Prolonged PD duration was a risk factor for hernia formation, and female gender was protective. Hernia formation during PD therapy may increase the risk of PD withdrawal., (Copyright © 2015 International Society for Peritoneal Dialysis.)

Aims: We investigated dialysis duration, dose of erythropoietin (EPO), and clinical manifestations in peritoneal dialysis (PD) patients with subclinical hypothyroidism., Methods: This cross-sectional study, performed in 3 centers, assessed 122 adult patients on PD for more than 6 months with regard to demographic data, dialysis duration, thyroid function, biochemical data, EPO dose, and clinical manifestations. Thyroid dysfunction was determined by serum thyroid-stimulating hormone, free thyroxine, total thyroxine, total triiodothyronine, antithyroid peroxidase antibodies, and auto-antibodies against thyroglobulin., Results: Of the 122 study patients, 98 (80.3%) were assessed as having euthyroidism; 19 (15.6%), subclinical hypothyroidism; and 5 (4.1%), subclinical hyperthyroidism. The proportion of women (74.2% vs. 57.1%, p = 0.038), the mean duration of PD (58.1 months vs. 37.9 months, p = 0.032), and the weighted mean monthly EPO dose (1.22 μg/kg vs. 1.64 μg/kg, p = 0.009) were significantly higher in the subclinical hypothyroidism group than in the euthyroidism group, but the prevalences of coronary artery disease and cerebrovascular disease were not. From the multivariate model, PD duration was more significant than sex as a risk factor for subclinical hypothyroidism (p = 0.0132)., Conclusions: Subclinical hypothyroidism is frequent in PD patients, especially female patients and patients with a longer PD duration. Compared with euthyroid patients, patients with subclinical hyperthyroidism need a higher dose of EPO to maintain a stable hemoglobin level.

Background: Few patients are able to resume peritoneal dialysis (PD) therapy after an episode of peritonitis that requires catheter removal. PD catheter loss is therefore regarded as an important index of patient morbidity. The aim of the present study was to evaluate factors influencing catheter loss in patients suffering from continuous ambulatory PD (CAPD) peritonitis., Patients and Methods: We retrospectively reviewed 579 episodes of CAPD peritonitis from 1999 to 2006 in a tertiary-care referral hospital. Demographic, biochemical, and microbiological characteristics were recorded. Episodes resulting in PD catheter removal (n = 68; 12%) were compared by both univariate and multivariate analyses with those in which PD catheters were preserved., Results: The incidence of PD catheter loss increased as the number of organisms cultured increased (p = 0.001). Also, PD catheter removal was more likely to occur after peritonitis episodes with low serum albumin level (p = 0.004), those with long duration of PD effluent leukocyte count remaining above 100/microL (p < 0.001), those with concomitant tunnel infection (p < 0.001), those with concomitant exit-site infection (p = 0.005), and those with presence of catastrophic intra-abdominal visceral events (p < 0.001). Duration on PD preceding the peritonitis episode was of borderline significance (p = 0.080). On the contrary, initial PD effluent leukocyte count and serum level of C-reactive protein were not predictive of PD catheter loss. Micro-organisms of the Enterobacteriaceae family were the major pathogens responsible for PD catheter loss following polymicrobial peritonitis. Furthermore, we found that there was no association between polymicrobial peritonitis and the catastrophic intra-abdominal visceral event, although both resulted in a greater incidence of PD catheter loss. Among the single-organism group in our population, the microbiological determinants of PD catheter loss included fungi (p < 0.001), anaerobes (p = 0.018), and Pseudomonas sp (borderline significance: p = 0.095)., Conclusion: PD catheter loss as a consequence of peritonitis is related primarily to hypoalbuminemia, longer duration of PD effluent leukocyte count remaining above 100/muL, the etiologic source of the infection, and the organism causing the infection. Peritonitis associated with concomitant tunnel or exit-site infections and abdominal catastrophes were more likely to proceed to PD catheter loss. The microbiological determinants of PD catheter loss in the present study included polymicrobial infections caused by Enterobacteriaceae as well as monomicrobial pseudomonal, anaerobic, and fungal infections.

In Taiwan, peritoneal dialysis (PD) was launched in 1984. Since then, the Taiwan Society of Nephrology (TSN) has taken the responsibility for supervising PD programs. All PD programs are required to pass evaluations from the TSN before inception. Every new PD patient receives individual training from a qualified PD nurse. The training, accompanied by a review test, is usually provided in the hospital during the week right after catheter implantation. To evaluate the effect of the patient training program on PD outcomes, we designed a retrospective observation study and reviewed the post-training tests of 100 new PD patients. The post-training test has 10 parts: anatomy and physiology, overview of chronic kidney disease, overview of PD, complications of peritonitis and exit-site infection, diet control, cardiovascular complications, PD skills and procedures, aseptic techniques, management of peritonitis, and routine tasks. The relationship between the post-training test scores and peritonitis was analyzed. Results showed that risk of peritonitis is not related to the post-training test score. However, based on our experiences, we believe that PD patient training should be lengthened and repeated periodically as suggested by the International Survey of Peritoneal Dialysis Training Programs. Training on certain issues such as the signs and symptoms of peritonitis should be especially enhanced.

Objective: To investigate the association of clinical parameters and serum anion gap with thyroid dysfunction and nodular goiter in continuous ambulatory peritoneal dialysis (CAPD) patients., Design: Cross-sectional study., Setting: Single dialysis unit and outpatient clinic., Patients: This study Included 89 uremic patients on CAPD. Gender ratio was 50 males to 39 females (M/F = 1.28); mean age was 54.8 years., Main Outcome Measures: We investigated the prevalence of nodular goiter and thyroid dysfunction with a 10-MHz high-frequency ultrasound scanner and immunoassay kits., Results: Nodular goiter was detected in 52.8% (47/89) of the CAPD patients. Patients with nodular goiter were older than those without goiter (57.7 vs 51.5 years, p < 0.05). Nodular goiter was found more frequently in females than in males (66.7% vs 44.0%, p < 0.05). Patients with nodular goiter had longer duration of CAPD than patients without goiter (51.6 +/- 42.9 vs 31.0 +/- 28.1 months, p < 0.02). In addition, CAPD patients with goiter had a higher serum anion gap (AG) (16.8 +/- 3.3 vs 14.0 +/- 4.5 mEq/L, p < 0.02) and a lower weekly creatinine clearance (55.9 +/- 12.6 vs 64.6 +/- 21.1 L/week/1.73 m2, p < 0.05) than patients without goiter. As serum AG gradually Increased, significant alteration of thyroid parameters developed In the following sequence: (1) reduction of total T3 level at an AG level of 15, (2) elevation of thyrotropin (TSH) and Increased prevalence of goiter at an AG of 18, and (3) reduction of free T4 and total T4 levels and elevation of TSH, with further increased frequency of goiter at an AG of 20 mEq/L., Conclusion: According to this study, age, gender, dialysis duration, serum AG, and weekly creatinine clearance are correlated with prevalence of goiter in CAPD patients. Sequential alteration of thyroid function and Increasing frequency of nodular goiter correlated with higher serum AG. There are two explanations for this correlation: the level of serum AG may be an indirect index of the level of serum goitrogens, and higher serum AG and Increased frequency of nodular goiters might be a reflection of loss of residual renal function. Therefore, thyroid function screening and goiter detection using ultrasound should be considered when examining CAPD patients with progressively elevating serum anion gap.

Objective: To investigate the induction of nitric oxide synthase type II (iNOS) in human peritoneal mesothelial cells (HPMC) using cytokines and bacterial lipopolysaccharide (LPS)., Design: Confluent monolayers of HPMC were exposed to cytokines [tumor necrosis factor alpha (TNFalpha), interleukin-1 beta (IL-1beta), interferon gamma (IFNgamma)] or LPS, individually or in various double and triple combinations, for 24-72 hours. Concentrations of nitrate and nitrite in the media were quantified using the Griess reaction and used as indirect indices of nitric oxide (NO) production. The expression of iNOS was assessed using reverse transcriptase-polymerase chain reaction (RT-PCR) and Western blot., Results: Neither single cytokines nor LPS was able to induce iNOS mRNA or NO production. Both double combinations of TNFalpha + IFNgamma and IL-1beta + IFNgamma were able to induce iNOS mRNA expression, but only TNFalpha + IFNgamma induced significant NO production. The triple combination of TNFalpha + IFNgamma + IL-1beta induced even more NO production than TNFalpha + IFNgamma. There was no constitutive NO synthase type III (eNOS) expression in HPMC., Conclusions: Certain combinations of cytokines could stimulate cultured HPMC to produce NO, and HPMC might be a source of intraperitoneal NO production during peritonitis.

Objective: To investigate the prevalence of nodular goiter and thyroid dysfunction in uremic patients undergoing hemodialysis (HD) and peritoneal dialysis., Design: Cross-sectional study., Setting: Single dialysis unit and outpatient clinic., Patients: The study included 221 patients [143 HD and 78 continuous ambulatory peritoneal dialysis (CAPD) patients] along with 135 consecutively selected outpatients as controls., Main Outcome Measures: Ultrasonography was used to detect patients' thyroid function and nodular goiter., Results: Nodular goiter was detected in 54.8% of the uremic patients and in 21.5% of the controls. Uremic patients had higher prevalence of thyroid dysfunction, which included reduced serum concentration of total T3, total T4, and free T4, and increased serum level of TSH. Hypothyroidism was also observed more frequently in uremic patients than in the control group (5.4% vs 0.7%, p < 0.05). Nodular goiter was more frequently found in females than in males (63.5% vs 48%, p < 0.05). Moreover, the prevalence of nodular goiter increased with age (p < 0.02) in uremic patients. Hemodialysis patients had a higher frequency of reduced total T3 level (46.9% vs 29.5%, p < 0.02). However, CAPD patients had lower T4 levels (6.23+/-1.82 microg/dL vs 7.15+/-1.99 microg/dL, p < 0.05)., Conclusion: Because of the high incidence of hypothyroidism and nodular goiter in uremic patients, screening of thyroid function and goiter detection with ultrasound should be considered in evaluation of end-stage renal disease patients.

Objective: To investigate the modulation of superoxide dismutase, glutathione peroxidase, and catalase by cytokines and endotoxin in human peritoneal mesothelial cells., Design: Cultured human peritoneal mesothelial cells were treated with various concentrations of interleukin-1 alpha, tumor necrosis factor-alpha (TNF-alpha), interleukin-6, interleukin-8, transforming growth factor-beta (TGF beta), and lipopolysaccharide. Cell morphology was observed and the activities of superoxide dismutase, catalase, and glutathione peroxidase were assayed. The antioxidant enzyme activities of human peritoneal mesothelial cells were also compared with those of human liver and kidney tissues., Results: Interleukin-1 alpha, TNF alpha, TGF beta, and lipopolysacharide caused dose-dependent cytotoxicities in mesothelial cells. The activities of these three antioxidant enzymes did not change after treatment with cytokines and endotoxin. The total superoxide dismutase activity of confluent human peritoneal mesothelial cells was found to be greater than that of human liver and kidney tissues and was composed mostly of manganese superoxide dismutase activity. Furthermore, glutathione peroxidase and catalase activities of human peritoneal mesothelial cells were lower than those of human liver and kidney tissues., Conclusion: In human peritoneal mesothelial cells, lack of induction of antioxidant enzymes by inflammatory cytokines, as well as high superoxide dismutase activity accompanied by insufficient glutathione peroxidase and catalase activities may both contribute to the susceptibility of these cells to oxidative damage. Therefore, appropriate management to decrease oxidative injury to the peritoneum should be taken into consideration when treating long-term continuous ambulatory peritoneal dialysis patients.