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It is unclear if the pharmacokinetics of vancomycin are the same during automated peritoneal dialysis (APD), where cycler exchanges may affect the systemic, peritoneal, and urinary disposition of drug. We conducted a prospective pharmacokinetic study evaluating the pharmacokinetics of vancomycin in plasma, dialysis fluid, and urine in peritonitis-negative patients on APD. Patients underwent four drug-free exchanges with 1.5% or 2.5% dextrose following the initial dwell period. Plasma, dialysis fluid, and urine was collected over the course of 7 days for pharmacokinetic analysis. Four patients completed the study with no adverse events. Following a median (range) dwell of 14.6 (14.2-17.6 h), the mean (±SD) observed maximum plasma concentration was 28.7 ± 4.9 mg/L with a mean bioavailability of 98.5 ± 1.4% prior to starting the cycler. The overall mean total plasma clearance estimated from study start to completion was 7.6 ± 1.2 ml/min. Mean total clearance during the dialytic exchange was 13.6 ± 4.9 ml/min. In patients with residual renal function, the mean vancomycin renal clearance was 3.1 ± 1.5 ml/min, representing 21.4%-58.9% of the overall total plasma clearance during the study period. Despite the small sample size, this pilot study suggests that the dwell time has important implications for systemic vancomycin exposure, time to therapeutic plasma concentration, and dosing. Dose is driven by dwell time, whereas the cycler determines the dosing interval. Rapid exchanges from APD will determine the frequency of dosing rather than the adequacy of absorption when vancomycin is given in the peritoneum.

Early innovations in the delivery of peritoneal dialysis (PD) markedly improved its acceptability and lowered peritonitis rates. The standard osmotic agent was, and continues to be dextrose, an agent that is not ideal as it is readily absorbed. The development of icodextrin-containing dialysis fluid has allowed a long dwell time to provide more effective ultrafiltration. The development of a smaller, more easily used automated cycler, led to an increase in the proportion of patients on the cycler as opposed to CAPD. Recently, new cyclers with better teaching tools and ease of use and communication with the training team have come on the market; data on outcomes using these cyclers are not yet available. Peritonitis continues to be a serious complication of PD although improvements in connectology and research on Staphylococcus aureus carriage have decreased peritonitis risk. Peritonitis rates continue to vary tremendously from one program to another, which may be in part due to failure to follow best demonstrated practices in training, care of the l catheter exit site, and prevention of peritonitis. Peritonitis rates should be expressed as episodes per year at risk and as organism-specific rates to allow comparisons from one program to another, from one period to another and from a program to the published literature. The term technique failure is misused in PD. Patients leave PD for a host of reasons including transplantation. Transfer from PD to hemodialysis can be planned and have an excellent outcome or can be delayed or done emergently and have a less optimal outcome. The life plan of the patient with ESRD needs to be not only considered but also periodically revised as circumstances and patient wishes change.

This randomized controlled trial tested an intervention, Sharing Patients’ Illness Representations to Increase Trust (SPIRIT), designed to enhance communication regarding end-of-life care between African Americans with end-stage renal disease (ESRD) and their chosen surrogate decision makers (N = 58 dyads). We used surveys and semi-structured interviews to determine the feasibility, acceptability, and preliminary effects of SPIRIT on patient and surrogate outcomes at 1 week and 3 months post-intervention. We also evaluated patients’ deaths and surrogates’ end-of-life decision making to assess surrogates’ perceptions of benefits and limitations of the SPIRIT while facing end-of-life decisions. We found that SPIRIT promoted communication between patients and their surrogates and was effective and well received by the participants.

Both peritoneal dialysis (PD) and hemodialysis (HD) patients have diminished quality of life (QOL) scores compared to healthy patients. QOL tends to decline over time, with the perception of the quality of physical health deteriorating more than mental health. However, many patients continue to feel hopeless, anxious, and worry about finances, loss of sexual function, family burden, and loss of independence. Depression is the most widely acknowledged psychosocial factor seen in patients with chronic kidney disease. Major depression occurs in 25% of patients facing impending dialysis. Once on PD, the proportion with major depression sharply declines to approximately 6%. This may be due to adjustment to dialysis, but may also be because depressive symptoms are associated with an increased risk of death. A low QOL score and depression are associated with higher comorbidity, poorer nutritional status, anemia, lower residual renal function, and increased hospitalization rates. Increased depressive scores are independently predictive of an elevated peritonitis risk, perhaps due to inattentiveness, or alternatively from a decrease in immune defenses. Small molecule clearances appear to have little to do with depressive symptoms. Depression is a significant problem in PD and other dialysis patients. There is an interrelationship between psychosocial factors, perception of illness, and clinical outcome that requires further study. Serial and simple measures of both depression and QOL should be obtained routinely in all PD patients. This permits rapid recognition of problems and may enhance patients' education on the importance of depression. Further research on interventions is urgently needed.

A 63-year-old man on ambulatory peritoneal dialysis (APD) developed peritonitis with Enterococcus faecalis, treated with 2 g intraperitoneal (IP) vancomycin, with rapid clearing of the effluent white blood cells, but persistence of positive cultures. Vancomycin was redosed on day 8 (2 g IP), and then weekly. Gentamicin 140 mg IP loading dose, followed by 40 mg IP once a day was added after cultures were still positive at 2 weeks. The two drugs were continued for six additional weeks. Although the patient was asymptomatic, the effluent cultures continued to grow E. faecalis and the catheter was replaced 2 months after the onset of peritonitis. There was no evidence of either tunnel infection or intra-abdominal abscess. Refractory peritonitis is defined as continuation of peritonitis after 5 days of appropriate therapy. This patient had persistently positive cultures but quickly became asymptomatic and signs of inflammation resolved readily. The most likely etiology appears to have been colonization of the slime layer of the intra-abdominal portion of the catheter with the organism. The vancomycin dosing schedule may have played a role in the persistently positive cultures. A recent pharmacokinetic study suggested that patients on APD require 35 mg/kg IP of vancomycin as a loading dose, followed by 15 mg/kg IP once a day, given in a long day exchange. Simultaneous placement and removal as a single procedure was successful in this patient and can be done safely in patients whose effluent white blood cell count (WBC) is less than 100/mm3. Most patients can then be subsequently managed by doing supine dialysis (using a cycler) with decreased exchange volumes and a dry abdomen until healing occurs (usually 1-2 weeks). In this way hemodialysis can be avoided. By minimizing the effect on the patient's lifestyle, the patient is more likely to agree to a catheter exchange.

Automated peritoneal dialysis (APD) is increasingly popular compared to continuous ambulatory peritoneal dialysis (CAPD). It not only can provide more solute clearance and ultrafiltration than its CAPD counterpart, but it is conducive to a more convenient lifestyle as well. Using relatively smaller-volume daytime dwells, with the use of larger-volume exchanges while the patient is recumbent during the night, is an attractive approach. Advantages of supine exchanges include greater small molecule clearances for equivalent flow rates and decreased intra-abdominal pressure per volume of dialysate (as intraperitoneal pressure parallels intraperitoneal volume). Urea nitrogen clearance can be optimally increased on APD by increasing both the exchange volume and the frequency of exchanges at night. This is even true for anuric low transporters. This approach allows daytime exchanges and volumes to be minimized. Historic studies in peritoneal dialysis including flow rate analysis, clearance and adequacy studies, as well as tolerance have primarily involved CAPD. As a result, there is a paucity of investigations involving APD. More research is required in APD related to these subjects.

The K-DOQI guidelines for bone metabolism in chronic kidney disease recommend measuring 25(OH) vitamin D levels and correcting deficiencies in stages 3 and 4 but not in ESRD. Most nephrologists are not concerned with 25(OH) vitamin D deficiency, despite evidence in hemodialysis patients that deficient vitamin D status [as measured by 25(OH) vitamin D levels] plays a role in bone disease. PD patients are often deficient in 25(OH) vitamin D in part because of peritoneal effluent losses, and correction may decrease muscle and bone complaints. Data from other populations are indicative of the importance of vitamin D in cancer surveillance and immune functioning. Randomized controlled trials of correction of 25(OH) vitamin D deficiency in both hemodialysis and peritoneal dialysis patients are urgently needed. vitamin D).

BACKGROUND Recombinant human erythropoietin has been approved for treatment of the anemia of renal failure since 1989, yet data regarding the safety and efficacy of this drug in pregnancy are limited. We used recombinant human erythropoietin to treat the anemia of renal disease in three pregnant women. CASES Nadir hematocrit values before initiation of erythropoietin were 19-23%. Erythropoietin, 50-160 U/kg/week subcutaneously, was begun at 14-26 weeks' gestation. Initially, the rise in hematocrit averaged 0.6-2% each week, with peak values of 26.7-32%. Iron supplementation was given simultaneously. Maternal and neonatal outcomes were favorable despite the development of preeclampsia or worsening renal function requiring early delivery. CONCLUSION In this small series, erythropoietin begun during the second trimester in a dose of about 100 U/kg/week, in conjunction with orally administered iron, appeared to be effective in treating the anemia of renal failure during pregnancy. Additional experience is needed to evaluate the safety of this medication during pregnancy.