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Objective: To determine the outcome of paediatric SLE (pSLE) patients with nephritis who developed acute renal failure (ARF). Efficacy and safety of treatment regimens were compared., Methods: A total of 249 pSLE patients were diagnosed and prospectively followed at a single centre between July 1973 and July 2003; 127 children (51%) had lupus nephritis. ARF was defined as serum creatinine of > 250 micromol/l or > 75% above baseline. Standardized assessments included clinical data and medications, laboratory testing, disease activity and damage scores were obtained. Subsequent renal flares were documented., Primary Outcome: renal function at last follow-up., Secondary Outcomes: treatment efficacy and safety. AZA- and cyclophosphamide (CYCLO)-treated patients were compared. Propensity score methods were applied to balance covariates. An intention to treat approach was chosen., Results: The ARF study cohort included 50 patients; 13 boys and 37 girls with a median age of 13.2 yrs at diagnosis and a mean follow-up of 45 months. Renal histology: Class III nephritis in 16; Class IV in 34. Dialysis requirement and disease activity were similar in both groups., Treatment: AZA in 33 patients, CYCLO in 9 and corticosteroids only in 8., Outcome: no statistically significant or clinically relevant differences were found for any of the outcome measures including last serum creatinine, time to renal flare, overall renal survival, disease activity over time, disease damage, mean annual corticosteroid dose and rate of infection., Conclusion: The treatment of renal failure in this pSLE cohort was associated with an excellent outcome. AZA and CYCLO were equally efficacious.

Background and Objectives: Despite reductions in the frequency of peritoneal dialysis (PD)-related infectious complications over time, peritonitis and catheter infection remain important causes of morbidity and mortality. Given the increasing number of elderly patients reaching end-stage renal disease, making informed decisions about PD utilization is contingent on an understanding of the infectious complications of PD in this population. We therefore studied the impact of age on infection rates, organisms and outcomes., Design, Setting, Participants and Measurements: On the basis of data collected from 1996 to 2005 in the multicenter Baxter Peritonitis Organism Exit sites Tunnel infections database, the study population included 4247 incident Canadian PD patients: 1265 patients aged > or =70 yr and 2982 patients aged <70 yr. We defined two eras of PD initiation: 1996 to 2000 and 2001 to 2005., Results: In a negative binomial model, older age was independently associated with a higher peritonitis rate (rate ratio [RR] 1.06 per decade increase; 95% CI 1.01 to 1.10; P = 0.008). However, this association was present only among those who initiated PD at an earlier time (RR 1.13 per decade increase; 95% CI 1.07 to 1.20; P < 0.001 in 1996 to 2000 versus 1.01 per decade increase; 95% CI 0.95 to 1.06; P = 0.81 in 2001 to 2005). Catheter-related infections were less frequent with increasing age regardless of era (RR 0.93 per decade increase; 95% CI 0.89 to 0.97)., Conclusions: The higher peritonitis rate observed in elderly patients may represent an era effect, as age was not associated with peritonitis among patients initiating PD between 2001 and 2005. In addition, catheter infection was less frequent with increasing age.

Background: Increasing numbers of patients on dialysis are undergoing coronary artery bypass grafting (CABG). We undertook this retrospective study to identify risk factors of operative mortality in dialysis patients who underwent CABG., Patients and Methods: We performed retrospective analysis of 105 patients who were on dialysis for at least two months before surgery and who underwent CABG in Toronto General Hospital from 1997 to 2006. Using prospectively collected data from the Division of Cardiovascular Surgery Database of Toronto General Hospital, we collected data on comorbidities, procedures, modality change during hospitalization, and operative outcomes. Logistic regression was used to assess risk factors of operative mortality., Results: One hundred and five maintenance dialysis patients (40 PD and 65 HD) who met the inclusion criteria were studied. Overall in-hospital mortality was 7.6%. Atrial fibrillation and pneumonia occurred in 16.2 and 9.5%, respectively, of all dialysis patients. Among PD patients, rates of post-operative dialysate leak and peritonitis were 10 and 12.5%, respectively. Among HD patients, 4.6% experienced post-operative AV access thrombosis. Logistic regression showed older age (>or=70 years) and peritoneal dialysis are independent risk factors of operative mortality., Conclusion: In this retrospective study, older patients on PD had higher operative mortality than HD patients. These findings suggest extra care should be taken when CABG is considered for PD patients over 70 years old. In this study we could not identify the reason(s) for the high mortality of elderly peritoneal dialysis patients undergoing CABG.

Increased submesothelial collagen deposition, loss of mesothelial cells and increased peritoneal vascularization of peritoneal membrane with vasculopathy leads to peritoneal fibrosis in a patient on long-term peritoneal dialysis (PD). This vascular proliferation within the peritoneum is associated with an increased expression of vascular endothelial growth factor (VEGF), which in turn leads to functional loss or deterioration of the peritoneal membrane over time. Vascular endothelial growth factor inhibitors may slow or even prevent vascular proliferation and subsequent loss of membrane function in peritoneal dialysis patient. We have observed the anti-VGEF effects of a tyrosine kinase inhibitor, sunitinib maleate, in a patient who was on this medication for renal cell carcinoma with extensive abdominal metastasis. The patient had also been on PD for 26 months at the time of the study. In this patient, the tyrosine kinase inhibitor helped to stabilize the abdominal metastasis as well as the thickness of the peritoneal membrane. The D/P creatinine ratio also remained stable. These observations suggest that this tyrosine kinase inhibitor may have prevented peritoneal membrane angiogenesis. We also observed that the patient did not have any further episode of peritonitis from gut-derived organisms, suggesting that stabilization of the intestinal metastasis prevented the transmural migration of bacteria from the gut, thereby preventing peritonitis.

Unlabelled: Objective. We compared patient characteristics, dialysis practice patterns and outcomes of peritoneal dialysis (PD) patients between one Chinese centre and one Canadian centre to determine whether observed differences in demographics and practices are associated with patient and technique survival., Methods: This study included all patients who started on PD between 1 January 2000 and 31 December 2004 at the University Health Network, University of Toronto, Canada and Renji Hospital, Shanghai Jiao Tong University School of Medicine, China. They were followed up from the date of PD initiation until death, cessation of PD, transfer to other centres or to the end of the study (31 December 2006)., Results: We studied 496 patients, 256 from the Canadian centre and 240 from the Chinese centre. Canadian patients were older and more likely to have diabetes and cardiovascular comorbidities at the initiation of PD, while the Chinese patients had lower residual renal function (RRF). More Canadian patients were treated with APD, whereas all Chinese patients were on CAPD with a lower PD volume. Crude patient survival rates at 1, 2, 3 and 5 years were similar between the two centres: 90%, 79%, 72% and 61% for Canadian and 90%, 79%, 71% and 64% for Chinese patients, respectively. After adjustment for demographic and clinical variables, there is no significant difference in mortality between Chinese patients and Canadian patients. Age, cardiovascular disease, diabetes, RRF and serum albumin were independent predictors of patient survival. The death-censored technique survival rates were significantly lower among the Canadian patients compared to Chinese patients. Chinese patients showed a lower risk of technique failure (HR 0.491, 95% CI 0.269-0.898, P = 0.021) after adjustment for patient characteristics. Chinese centre, BMI, serum albumin and gender were independent predictors of technique survival. The average peritonitis rate was one episode every 36.1 patient-months in Canadian patients and one episode every 60.6 patient-months in their Chinese counterparts., Conclusion: Patient characteristics, dialysis practice patterns and outcomes vary between Canadian and Chinese patients. The variability in patient outcomes between these two centres indicates that further improvements may be possible in both centres. We have identified several areas for improving outcomes.

Background: Angiotensin-converting enzyme (ACE) inhibitors have been shown to improve outcome in patients with renal failure not on dialysis therapy and patients on haemodialysis (HD). However, their effect on survival has not been studied in peritoneal dialysis (PD) patients. The present study examined the association between therapy with ACE inhibitor/ARB and mortality in patients undergoing chronic PD., Methods: All patients who commenced PD between 1 January 2000 and 31 December 2005 at the University Health Network were included. Patients were grouped according to whether they had been treated with ACE inhibitor/ARB. They were followed up from the date of PD initiation until death, cessation of PD, transfer to other centres or to the end of the study (31 December 2006)., Results: A total of 306 patients were included in the study. One hundred and sixty-five were treated with ACE inhibitors/ARB (treated group) and 141 were not (untreated group). The treated group patients were younger (56.9 +/- 16.6 versus 62.3 +/- 17.8 years, P < 0.01) and more likely to have a history of hypertension than the untreated group. At the initiation of PD, systolic and diastolic blood pressures were higher in the treated than the untreated group (138.8 +/- 21.8 versus 128.6 +/- 22.4 mmHg, P < 0.001; 79.8 +/- 14.1 versus 74.5 +/- 12.5 mmHg, P = 0.001) and remained significantly higher during the follow-up (133.5 +/- 16.4 versus 125.1 +/- 16.7 mmHg; 77.3 +/- 9.8 versus 73.2 +/- 9.7 mmHg, both P < 0.001). The treated group had a significantly longer survival compared to the untreated group (log rank 19.191, P < 0.001). After adjusting for age, blood pressure and other demographic and clinical parameters, multivariable Cox proportional hazards modelling showed that the use of ACE inhibitor/ARB was associated with 62% reduced risk for death (HR 0.382, 95% CI 0.232-0.631, P < 0.001)., Conclusion: In this retrospective analysis, ACE inhibitor/ ARB therapy was associated with a dramatically reduced mortality in patients on peritoneal dialysis independent of blood pressure and other clinical and demographic variables.

Patients returning to peritoneal dialysis after renal allograft loss are an increasing segment of the end-stage renal disease population. Non-transplant nephrologists will be managing the short- and long-term complications of chronic immunosuppression in these patients. In this case report, the use of sirolimus is described in a patient who developed a significant peritoneal dialysis catheter exit-site leak delaying the initiation of dialysis. The risk of impaired wound healing at the time of peritoneal dialysis catheter implantation must be considered when bridging patients from transplantation to peritoneal dialysis. Particular caution should be paid to the use of sirolimus during this period.

Objective: Peritonitis caused by enteric organisms in peritoneal dialysis (PD) patients is associated with greater morbidity and mortality than peritonitis with non-enteric organisms. One reported risk factor for enteric peritonitis (EP) is gastric acid suppression, with two small studies providing conflicting results. The objective of this study was to determine, using a larger patient population, whether gastric acid suppressants are associated with an increased risk of EP., Patients and Methods: Using a single-center case-control design, information on episodes of EP occurring between 2003 and 2006 was collected. Control episodes were all non-enteric episodes of peritonitis that occurred during the same time interval. Proton pump inhibitor (PPI) or H(2)-blocker (H(2)B) use prior to development of peritonitis was documented., Results: A total of 228 peritonitis episodes among 137 patients met inclusion criteria. In 32% of episodes, the causative organism was enteric. Gastric acid suppressant use was documented in 46% of episodes, with the majority on PPIs. Overall, gastric acid suppression was not associated with a higher EP risk (p = 0.17). In a post hoc analysis, PPIs were not associated with EP [odds ratio (OR) 1.3, 95% confidence interval (CI) 0.7-2.4; p = 0.42], whereas H(2)Bs were associated with a higher risk of EP (OR 2.9, 95% CI 1.1-7.7; p = 0.04), although the number of patients on H(2)Bs was small., Conclusion: Overall, gastric acid suppression was not associated with an increased risk of peritonitis with enteric organisms. While PPI use appears to be safe for PD patients with appropriate indications, the potential risk of EP with H(2)Bs requires further investigation.

Background: Diabetic patients with end-stage renal disease (ESRD) are at high risk for developing foot complications and few have studied this complication in the diabetic patients treated with peritoneal dialysis (PD). The purpose of this study was to examine peripheral vascular disease (PVD) in diabetic patients with ESRD, who are being treated with PD, and to identify those factors that may contribute to its development., Patients: We reviewed retrospectively the charts of 71 diabetic patients who started PD between January 1999 and January 2006, inclusive, and recorded their demographic data, their treatment regimens, their complications and the results of biochemical investigation(s) at the beginning and throughout their follow-up period. All patients were under the care of a chiropodist who examined them at regular intervals and more often when needed. We divided the patients into two groups with respect to the presence of complications in the lower extremities, such as ulcers, open wounds, osteomyelitis, necrotizing or gangrenous lesions, and amputations, intermittent claudication and/or the presence on an imaging examination of changes in the leg vessels consistent with vascular disease., Results: 33 of the 71 patients had some type of a foot lesion. There were 8 amputations in the course of 176 patient-years (2 double amputations), or 1 amputation per 30 PD patient-years. Those patients with foot complications were treated more frequently with CCPD (p<0.05), more often had peripheral neuropathy (p<0.002), as well as coronary artery disease (p<0.044). They had lower serum albumin (p<0.005), significantly higher serum phosphorus (p<0.047) and they received higher doses of erythropoietin (p<0.042). There was no statistically significant difference between the groups regarding sex, age at initiation of PD, type of diabetes, use of insulin, levels of HbA(1c), body mass index (BMI), presence of retinopathy, cerebral vascular disease, hyperlipidemia, smoking, rate of transplantation, rate of drop-out from PD, time-averaged Kt/V, creatinine clearance, serum calcium, Ca x P and intact PTH. In a multiple logistics regression model, only peripheral neuropathy and hypoalbuminemia were independently associated with the development of lower-extremity complications (p<0.0066 and p <0.026, respectively). One-, two- and three-year cumulative survival of the whole group was 91.5%, 78.8% and 69%, respectively. Patients with foot lesions had a lower survival than those without. Interestingly though, those patients, who had had an amputation, survived as long as those patients, who did not have foot complications at all., Conclusion: In conclusion, compared to reports in the literature, our diabetic patients on PD had a lower rate of foot complications and amputation probably because of early intervention by our chiropodist. This fact stresses the need for constant and expert monitoring of the condition of the diabetic patient's feet, especially in those with low serum albumin and peripheral neuropathy.

Patients returning to dialysis after graft loss (DAGL) are an increasing segment of the end-stage renal disease (ESRD) population. It is unclear whether patients with previous graft loss have equivalent or reduced survival from the time of restarting dialysis when compared with ESRD patients initiating dialysis for the first time. Moreover, the impact of dialysis modality on the survival of patients returning to DAGL is not known. Studies of patients with transplant graft failure returning to hemodialysis (HD) have suggested decreased survival when compared with transplant-naïve dialysis patients, yet some studies of patients with graft failure returning to peritoneal dialysis (PD) have demonstrated equivalent survival. Based on these data, it is unclear whether survival differences may exist between the dialysis modalities, and if they do, whether they can be attributed to either differences in patient characteristics or to factors related to the dialysis modalities. For patients starting back onto dialysis, in whom preservation of residual renal function is important, it is also unclear how immunosuppression reduction or transplant nephrectomy may affect survival. In this review, we will summarize the available literature on survival rates of patients returning to DAGL; compare and contrast survival after initiation of HD and PD and discuss what is known about the impact of transplant nephrectomy and the different approaches to immunosuppression reduction. Practical considerations will be discussed with a specific emphasis on patients treated by PD.

End stage renal disease is a serious complication in heart or heart-lung transplant recipients and is associated with high morbidity and mortality. The majority of these patients are currently treated with hemodialysis. Since there are no randomized control trials comparing hemodialysis to peritoneal dialysis in this patient population, the potential beneficial effects of peritoneal dialysis remain largely unknown. We compared the clinical outcome of such patients on peritoneal dialysis with another group on hemodialysis. Our results indicate that patients on peritoneal dialysis had fewer episodes of congestive heart failure, fluid overload and a lower overall hospitalization rate, despite having worse cardiac function than patients on hemodialysis.

Background: Patients on continuous ambulatory peritoneal dialysis (CAPD) who have high small-molecule peritoneal transport have increased mortality., Objective: To investigate the impact of baseline peritoneal transport characteristics on patient and technique survival in incident peritoneal dialysis (PD) patients, most of whom are on automated PD (APD), with the use of icodextrin., Design: Retrospective observational cohort study., Setting: A single PD unit., Patients and Methods: 193 new patients that began PD between January 2000 and September 2004, and had an initial peritoneal equilibration test within 6 months of commencement of PD. Patients were divided into low (L), low average (LA), high average (HA), and high (H) peritoneal transport groups. Death-censored technique failure and patient survival were examined., Results: Of the 193 patients, 151 (78.1%) were on APD or on APD with icodextrin or on CAPD with icodextrin. At the end of 1, 3, and 5 years, patient survival was 91%, 82%, and 67% in LA group; 95%, 77%, and 69% in HA group; and 96%, 71%, and 71% in H group. Technique survival was 100%, 90%, and 77% in LA group; 96%, 84%, and 72% in HA group; and 92%, 87%, and 77% in H group. High peritoneal permeability did not predict worse patient survival or technique failure, while age, diabetes, a lower glomerular filtration rate, and high body mass index (> or =30 kg/m(2)) were independent predictors of death., Conclusion: This study suggests that higher peritoneal transport is not a significant independent risk factor for either mortality or death-censored technique failure. The favorable outcome for high transporters in this study may be due to improved management of volume status by the increased use of APD and the use of icodextrin-based dialysis fluid.

A preliminary report from our unit previously suggested that diabetic patients on continuous cyclic peritoneal dialysis (CCPD) have higher ultrafiltration (UF) with icodextrin than non-diabetic patients. To confirm this observation, we did a retrospective analysis of our patients (17 diabetic and 23 non-diabetic) who were on stable CCPD prescription using a long-day dwell with icodextrin. We collected daily UF data from these patients' records for 30 days. The two groups showed no significant difference with respect to age, gender, hemoglobin, serum albumin, peritoneal dialysis and icodextrin vintage, peritoneal membrane characteristics, CCPD prescription, and peritoneal and residual renal clearance. The overnight net UF achieved with the cycler with standard glucose dialysate was similar in the two groups (850+/-379 in diabetic vs 713+/-484 ml/day in non-diabetic, P=0.34). However, UF with icodextrin during the day dwell (14.8+/-0.8 h) was significantly higher in diabetics than non-diabetics (348+/-198 vs 137+/-311 ml/day, P=0.02). Our results show that icodextrin produces significantly higher UF in long-day dwell in diabetic ESRD patients on CCPD than in non-diabetic patients. The reason for this difference is not clear.

Objective: It has been proposed that biocompatible bicarbonate/lactate based (Bic/Lac), physiologic-pH peritoneal dialysis (PD) solutions will be beneficial in long-term PD. However, we do not yet have detailed knowledge concerning the comparative physiology of buffer transport for these new solutions and their impact on underlying peritoneal transport of solutes and ultrafiltration (UF). The purpose of this study was to investigate the profile of buffer handling and peritoneal membrane transport characteristics during a single dwell of the new Bic/Lac-based versus standard lactate-based (Lac) PD solution., Methods: In this prospective crossover study, we compared a 25 mmol/L bicarbonate/15 mmol/L lactate buffered, physiologic pH, low glucose degradation product (GDP) solution (Physioneal; Baxter Healthcare, McGaw Park, Illinois, USA) with a standard lactate buffered, acidic pH, conventional solution (Dianeal; Baxter). 18 patients underwent two peritoneal equilibration tests (PETs) with 2.5% Dianeal and 2.5% Physioneal separated by 1 week. Buffer transport, mass transfer area coefficients (MTACs), solute transport, and UF were determined for the two PETs. All bags were weighed by a nurse before instillation and after drainage to assess the net UF in each dwell., Results: 18 patients that met the inclusion criteria were enrolled in this study. Whereas intraperitoneal pH remained constant at 7.52 +/- 0.11 throughout the dwell with the Bic/Lac solution, pH was still in the acidic range with the Lac solution after 1 hour (7.29 +/- 0.13, p < 0.001); this difference disappeared after the second hour of dwell. The MTACs for creatinine (10.68 +/- 3.66 vs 10.73 +/- 2.96 mL/minute/1.73 m(2), p > 0.05) and urea (27.94 +/- 10.50 vs 27.62 +/- 6.95 mL/min/1.73 m(2), p > 0.05), for Bic/Lac versus Lac respectively, did not differ between these two solutions; transport of glucose and other solutes was also similar. However, after a 4-hour dwell with Bic/Lac solution, net UF was significantly lower than that observed with Lac solution (274.2 +/- 223.3 mL vs 366.1 +/- 217.3 mL, p = 0.026)., Conclusions: Compared to standard Lac-based solution, Bic/Lac based, pH neutral, low-GDP solution avoids intraperitoneal acidity. Peritoneal mass transport kinetics are similar for small solutes. Net UF is significantly lower with Bic/Lac solution; the mechanism for this is unclear.

Listeria monocytogenes (LM) is one of the rare microorganisms causing peritonitis in peritoneal dialysis (PD) patients. We report a sporadic case of peritonitis caused by LM in a young female PD patient with lupus receiving corticosteroid therapy, who presented with abdominal pain, cloudy PD effluent, nausea, and conjunctivitis. The effluent showed a high PD effluent white cell count and monocytosis, and gram staining showed gram-positive bacilli in single or short chains and PD effluent culture grew LM. She was treated successfully with beta lactum antibiotics. LM peritonitis should be suspected if a patient presents with gram-positive bacilli and monocytosis in dialysis effluent.

Noninfectious complications of peritoneal dialysis (PD) are increasing in relative importance due to success in decreasing the rate of PD peritonitis. Mechanical catheter complications are emerging as an important cause of technique failure at the same time as experience with PD is declining in North America. There is also increasing interest in metabolic complications of PD and in glucose-sparing strategies to reduce the risk for hyperglycemia, hyperinsulinemia, and hyperleptinemia. This clinical commentary focuses on these noninfectious complications of PD.

Background and Objectives: Nocturnal home hemodialysis provides excellent biochemical and metabolic control of uremia; however, extensive training is necessary and technical barriers exist for intensive home hemodialysis compared with the relative simplicity of peritoneal dialysis. It was hypothesized that nocturnal home hemodialysis is associated with improved quality of life but higher illness intrusiveness compared with peritoneal dialysis., Design, Setting, Participants, & Measurements: All home dialysis patients at the University Health Network were approached to complete the Kidney Disease Quality of Life-Short Form, Beck Depression Inventory, and Illness Intrusiveness Survey during February to June 2006., Results: Sixty-nine percent of all eligible patients completed the survey. Of the three domains derived from the Kidney Disease Quality of Life-Short Form, there was no difference in the kidney disease component summary, physical component summary, and the mental component summary between the two groups. There was a trend toward better sexual function in the nocturnal home hemodialysis group; however, nocturnal home hemodialysis patients experienced less social support than the peritoneal dialysis group. There was no difference between the nocturnal home hemodialysis and peritoneal dialysis patients with respect to the Beck Depression Index. Total illness intrusiveness score was similar between the nocturnal home hemodialysis and peritoneal dialysis patients., Conclusions: This study suggests that nocturnal home hemodialysis is not perceived as a more intrusive treatment and demonstrates that patients who are on peritoneal dialysis have similar perceived symptomatic control of their kidney disease.

In recent years, there have been some interesting advances in the science and practice of peritoneal dialysis (PD). This review focuses on selected technological advances and the impact that these changes may have on this modality. New, so-called "biocompatible" fluids have more physiologic pH and reduced glucose degradation products. These new fluids may reduce the deleterious effects of chronic exposure to the peritoneal membrane. However, enthusiasm for these new fluids is outstripping rigorous evidence that they change patient outcome. Continuous-flow PD offers a way to increase dramatically small solute clearance. However, there are significant technological barriers to the implementation of this kind of dialysis. Furthermore, there is little evidence that augmented small solute clearance will improve survival in PD patients. Finally, new catheter insertion techniques provide perhaps the most practical advances in allowing successful commencement of this excellent home dialysis modality.

The publication of the CHOICE study, which compared survival of US hemodialysis and peritoneal dialysis patients, has re-opened the debate about the relative merits of the two dialysis modalities. The principal focus of the research and associated commentary, however, is about which modality is associated with the longest life expectancy. What appears to be missing, however, in the quagmire of propensity scores, comorbidity and confounding factors is that outcomes other than duration of survival must be addressed in discussions of the merits of renal replacement therapies. Home dialysis is very different from in-center hemodialysis, and each therapy has advantages and disadvantages that will have different implications for each patient. Given that overall survival is comparable between home peritoneal dialysis and in-center hemodialysis, we need to stop focusing so much on survival time and let the informed patient choose the modality.

Objectives: The purpose of this study was to evaluate the outcome and to identify predictors of mortality in elderly patients on chronic peritoneal dialysis (CPD)., Methods: We retrospectively reviewed the charts of patients who started on CPD at the Division of Nephrology, University Health Network (UHN), Toronto, from 1 January 1994 to 31 December 2001. Patients were divided into three different age groups (/=75 years). Baseline variables included demographics, information on primary kidney disease, comorbidities when dialysis was first started, and initial biochemical data such as serum albumin, serum calcium (corrected for protein), phosphate, hemoglobin (Hb), total cholesterol, and triglyceride. The effects of these variables on survival were studied using a univariate procedure and then analyzed using multivariate Cox proportional hazards models in order to evaluate their independent relation to mortality., Results: This study included 358 patients, among whom 213 (59.5%) were /=75 years old. Mean actuarial (death-censored) technique survival for the overall study population was 72.4 months (95% confidence interval [CI]: 66.3-78.5); in the /=75 year-old groups mean survivals were 74.4, 62.0, and 64.5 months, respectively. The death-censored technique survival for the elderly patients was not statistically significantly different from that in young patients (P = 0.778). In the overall study population, the mean patient survival was 70.4 months (95% CI 64.2-76.6), while the mean survivals for the /=75 year-old groups were 82.3, 54.0, and 50.0 months, respectively. The overall survival rates at 12 months were 98%, 84%, and 85% for the /=75 year-old groups, respectively. Not surprisingly, the survival of elderly patients on CPD is shorter than that of younger patients (P = 0.000). There were no significant differences between the two elderly groups (P = 0.439). Mortality was predicted by lower initial serum total cholesterol and albumin as well as higher serum calcium levels., Conclusion: Our study shows that elderly patients starting CPD had a death-censored technique survival comparable to that of younger patients. As expected, the survival of elderly patients on CPD was shorter than the survival of younger patients. Lower initial serum total cholesterol and albumin as well as higher initial serum calcium were associated with mortality in the elderly population. Our findings indicate that chronic peritoneal dialysis is a successful dialysis option for elderly patients with end stage renal disease. Measures to improve their nutritional state and achieve normalization of serum calcium might improve their survival.

Background: The present study was aimed at investigating the factors related to hypo-responsiveness to erythropoietin in patients on chronic peritoneal dialysis (PD)., Methods: We studied 44 patients with end-stage renal disease who had been on PD for more than 6 months and on erythropoietin (EPO) >/=6,000 U/week for more than 3 months. We expressed EPO resistance index (ERI) as weekly EPO dose per hematocrit (Hct) per body weight. The dose of EPO was titrated to maintain a target Hct level between 33% and 36%. Patients were divided into two groups according to weekly EPO dose. We compared the various factors in those two groups and, by using correlation and linear regression analysis, investigated factors that might predict EPO resistance., Results: There were 13 patients in the EPO <150 U/kg per week group and 31 patients in the EPO >/=150 U/kg per week group. Among those 31 patients, there were five patients on EPO >/=300 U/kg per week. Compared to the EPO <150 U/kg per week group, the EPO >/=150 U/kg per week group had a lower normalized protein catabolic rate (nPCR), lower level of serum albumin and higher C-reactive protein (CRP). Correlation analysis showed that the ERI had a statistically significant correlation with CRP (r = 0.303, P < 0.05), serum albumin (r = -0.26, P < 0.05), parathyroid hormone (PTH) (r = -0.307, P < 0.05) and nPCR (r = -0.259, P < 0.05). These results show that CRP, serum albumin, PTH and nPCR are factors related to hypo-responsiveness. Multiple stepwise linear regression analysis showed that CRP was the most important independent predictor of EPO hypo-responsiveness., Conclusion: CRP, serum albumin, nPCR and PTH are factors related to hypo-responsiveness. Inflammation contributes significantly to EPO hypo-responsiveness.

Background: Detailed descriptive studies focusing on streptococcal peritonitis in patients on peritoneal dialysis are lacking. Most of the current information is available through isolated case reports., Methods: We conducted a retrospective analysis of our peritoneal dialysis (PD) peritonitis database over the last decade to study the clinical profile and treatment outcomes of streptococcal peritonitis., Results: A total of 68 patients (age: 57.12 +/- 16.6 years; male: 58.7%) with 104 episodes of streptococcal peritonitis (11.7% of total peritonitis) were identified. Of the patients, 18 (26.4%) were considered immunocompromised [failed renal transplant, systemic lupus erythematosus (SLE)] and 28 (41.1%) had diabetes. Streptococcus viridans accounted for the majority (94 episodes: 90.3%) of the streptococcal peritonitis. One patient developed S. viridans peritonitis after dental cleaning without antibiotic prophylaxis. Two (1.9%) infections with S. agalactiae and S. bovis each and seven (6.7%) with non-haemolytic Streptococcus were noted. Three patients had hospital-acquired infection. Twenty-six (25%) episodes needed 8 +/- 5.9 days of hospitalization. Concurrent infection with two organisms accounted for 17 (16.3%) episodes. Cefazolin (71) and vancomycin (29) were the primary antibiotics used for the treatment. Five episodes needed two antibiotics and one patient required antifungal treatment. A third of the patients (33.3%) had peritonitis that resolved slowly, although the majority of those (94%) did ultimately resolve with antibiotics alone. Five (4.8%) episodes required removal of the PD catheter. Three of them were associated with dual infections (one each with yeast, Stenotrophomonas and Enterococcus). Relapse occurred in eight (7.6%) episodes, and 11 (10.5%) recurred over the period from 4 weeks to 6 months after treatment., Conclusions: Streptococci remain a significant cause of PD peritonitis. Viridans strep is the primary subtype responsible. Isolated infections with these organisms are associated with slower response, good outcome and higher rates of recurrence.

Objective: To review the feasibility of undertaking elective hernia repair in peritoneal dialysis (PD) patients without converting them to hemodialysis., Design: A 10-year retrospective review of prospectively collected data., Setting: PD unit of a university-based hospital., Patients and Methods: All patients received regular exchanges until the morning of the surgery and remained off dialysis for the first 48 hours postoperatively. After that, PD was gradually reintroduced. The patients on continuous ambulatory PD (CAPD) received intermittent PD (IPD) 3 times per week for 10 hours per day for 2 weeks, followed by 5 exchanges of low volume (1-1.5 L) CAPD for 2 weeks, returning to the pre-surgery prescription by 4 weeks. Patients on continuous cycling PD (CCPD) received 1 week of IPD followed by 4 weeks of nocturnal IPD and returned to the original dose in 5 weeks. Between 1 April 1995 and 31 March 2005, 50 consecutive patients were managed by this protocol. Average age was 65 years and 67.7% were males. The original disease was diabetes mellitus (19 patients), hypertension (6), chronic glomerulonephritis (13), polycystic kidney disease (6), and others (6). The types of abdominal hernias included umbilical (25 patients), inguinal (18), incisional (5), and epigastric (2). 42 patients were on CAPD and 8 on CCPD. Average duration of PD prior to development of hernia was 16.4 months., Results: Average pre-surgery creatinine was 673 mumol/L, increasing to 968 mumol/L on IPD. Serum potassium increased from 3.4 to 4.7 mmol/L. No episodes of hyperkalemia were noted. The average total follow-up was 33.4 months. None of the patients had leakage or early hernia recurrence due to early resumption of PD; 13 patients had recurrence of the same hernia after a median 19.9 months; 4 patients had hernias at different sites after an average of 55 months., Conclusions: Based on this experience, we recommend that PD patients undergoing elective abdominal hernia surgery should continue PD according to the prescribed protocol. Interim hemodialytic support does not appear to be necessary in most patients.

Peritoneal dialysis treats uraemia in a way different from hemodialysis. The continuous nature of peritoneal dialysis optimises the removal of uraemic toxins of larger molecular weight, the so-called 'middle molecules'. Initially, there was an appreciation of the efficacy of this kind of slow, continuous dialysis. However, with the growing emphasis on adequacy as defined by small solute kinetics, blood purification by peritoneal dialysis was considered to be inferior to that performed with hemodialysis. With the subsequent publication of studies showing a lack of correlation of small solute clearance parameters with outcome in peritoneal dialysis, attention is again being paid to the benefits of continuous dialysis that treats renal failure in a way not quantifiable by small solute kinetics.

Background: Secondary hyperparathyroidism (SHPTH) is present in many patients with end-stage renal disease (ESRD) and has been linked to uremic bone disease. Parathyroid hormone (PTH) levels are affected by calcium, vitamin D, and phosphorus. Recent data suggests that serum magnesium may also modulate PTH levels., Objective: The aim of this retrospective study was to investigate the impact of different calcium (Ca) and magnesium (Mg) concentrations of dialysis solutions on serum Mg and serum PTH levels in peritoneal dialysis (PD) patients., Patients and Methods: Two groups of PD patients-group A (n = 17) on "standard" Ca and Mg dialysis solution (SCa-MgD) (Ca: 1.62 mmol/l, Mg: 0.75 mmol/l and Lactate 35 mmol/l), and group B (n = 29) on "low" Ca and Mg dialysis solution (LCa-MgD) (Ca: 1.25 mmol/l, Mg: 0.25 mmol/l and Lactate 40 mmol/l), on PD for more than 6 months, were studied. Calcium carbonate (CaCO3) was used as the phosphate (P) binder in 87% (40/46) of the patients. Biochemical parameters were evaluated every 1-2 months over 6 months and the mean values were computed., Results: No significant differences were found between the two groups in all parameters except for serum Mg and PTH. Serum Mg was higher in SCa-MgD group compared to those in the LCa-MgD group (1.05 +/- 0.19 vs 0.90 +/- 0.23 mmol/l, respectively) and serum PTH was higher in LCa-MgD group compared to those in SCa-MgD group (72.3 +/- 64.2 vs 31.1 +/- 39.0 pmol/l, respectively) even though serum Ca was not different. There was a statistically significant inverse correlation between serum Mg and PTH levels (r = -0.357, p < 0.05)., Conclusion: Serum Mg is lower and serum PTH higher in patients dialyzed with lower Mg concentration dialysis solution compared to those with higher Mg concentration dialysis solution. Our study confirms previous reports that serum Mg may have a suppressive role on PTH synthesis and/or secretion, and thus may play a role in pathogenesis of adynamic bone disease that often develops in patients on chronic PD with high calcium and high magnesium concentrations.

Background: Mineral metabolism has emerged as an important predictor of morbidity and mortality in dialysis patients. Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines for bone metabolism and disease in chronic kidney disease (CKD) recommend that, in Stage 5 CKD, the target levels for calcium (Ca) (corrected for serum albumin), phosphate (P), calcium x phosphate (CaxP) product and parathyroid hormone (PTH) levels should be maintained at 8.4-9.5 mg/dl, 3.5-5.5 mg/dl, <55 mg2/dl2 and 150-300 pg/ml, respectively., Objectives: To evaluate our ability to achieve K/DOQI guidelines for bone metabolism and disease targets in our patients and to compare them between patients on hemodialysis (HD) and peritoneal dialysis (PD) and also with those reported in the literature., Methods: We reviewed bone metabolism laboratory parameters in 57 HD patients and 69 PD patients, who had been on dialysis for more than 9 months., Results: The percentage of patients whose serum Ca, P, CaxP product and PTH were within K/DOQI recommended target ranges were 46%, 53%, 77% and 28% in HD patients and 52%, 65%, 77% and 23% in PD patients, respectively. There were no significant differences between HD and PD patients in the percentage of all parameters that were within K/DOQI recommended target ranges. The percentage of our HD patients who had Ca, P, and PTH levels within recommended target range was similar to those in previous reports., Conclusion: In our unit, the management of bone and mineral metabolism in HD and PD patients is still far short of meeting K/DOQI guidelines. These findings appear similar in HD and PD patients. Our findings resemble those reported in the literature.

Although advances have been made in the treatment and prevention of peritoneal dialysis (PD) peritonitis, these infections are still a significant source of technique failure, morbidity, and mortality in the end-stage renal disease population. Currently, it is unclear whether PD patients who experience an episode of peritonitis early in the course of their therapy are more vulnerable to the complications of peritonitis. Using retrospective data collected at the Toronto General Hospital Home Peritoneal Dialysis Unit between January 1, 1998, and December 31, 2004, we compared technique and patient outcomes between PD patients developing "early-onset" peritonitis and a matched control group of PD patients. "Early-onset" peritonitis was defined as peritonitis occurring within 3 months of PD catheter insertion. Outcomes included survival on PD or the combined endpoint of technique failure (transfer to hemodialysis) or death. The early-onset cohort was younger than the control group and had a higher peritonitis rate (1.18 episodes vs. 0.28 episodes per patient-year). Gram-positive micro-organisms, particularly coagulase-negative staphylococci, were the most common cause of peritonitis. At the conclusion of the study, 8 patients (38.1%) in the early-onset cohort had transferred to hemodialysis, 2 patients (9.5%) had died of cardiac complications, and 11 patients (52.4%) remained on PD. The combined rate of technique failure and death in the early-onset group was almost twice as high as that in the control group (0.282 vs. 0.175 per patient-year). Time to the composite end-point of technique failure or death did not significantly differ between the two groups (p = 0.26). In summary, there is an important trend toward increased death and technique failure in PD patients who develop peritonitis early in the course of their PD therapy.

Background: Since the original description of continuous flow PD (CFPD) by Shinaberger, there has been interest in the utility of this modality to augment small solute clearances in those on PD., Methods/results: The clinical and theoretical treatment of CFPD regimens and the changing views of small solute clearance and outcome in dialysis since the publication of several important randomized, controlled trials are reviewed., Conclusion: There is little justification to promote CFPD solely on the basis of increased small solute clearance, given the lack of robust association between this measure and outcome in PD patients. Furthermore, leaving the abdomen empty between CFPD sessions may seriously compromise removal of middle molecular weight uremic toxins, one of the presumed strengths of conventional PD.

Continuous renal replacement therapy (CRRT) is widely used in critically ill patients with acute renal failure (ARF). The survival of patients who require CRRT and the factors predicting their outcomes are not well defined. We sought to identify clinical features to predict survival in patients treated with CRRT. We reviewed the charts of all patients who received CRRT at the Toronto General Hospital during the year 2002. Our cohort (n=85) represented 97% of patients treated with this modality in 3 critical care units. We identified demographic variables, underlying diagnoses, transplantation status, location (medical-surgical, coronary, or cardiovascular surgery intensive care units), CRRT duration, baseline estimated glomerular filtration rate (eGFR), and presence of oliguria (<400 mL/day) on the day of CRRT initiation. The principal outcome was survival to hospital discharge. Among those alive at discharge, we assessed whether there was an ongoing need for renal replacement therapy. Greater than one-third (38%, 32/85) of patients survived to hospital discharge. Three (9%) survivors remained dialysis-dependent at the time of discharge. Survivors were younger than nonsurvivors (mean age 56 vs. 60 years), were on CRRT for a shorter duration (7 vs. 13 days), and had a higher baseline eGFR (74 vs. 62 mL/min/m(2)). Patient survival varied among different critical care units (medical surgical 33%, coronary 38%, and cardiovascular surgery 45%). Multivariable logistic regression revealed that shorter duration of CRRT, nonoliguria, and baseline eGFR >60 mL/min/m(2) were independently associated with survival to hospital discharge (p<0.05). Critically ill patients with ARF who require CRRT continue to have high in-hospital mortality. A shorter period of CRRT dependence, nonoliguria and higher baseline renal function may predict a more favorable prognosis. The majority of CRRT patients who survive their critical illness are independent of dialysis at the time of hospital discharge.

The preservation residual renal function (RRF) is important for adequacy of peritoneal dialysis. Oxidative stress from intravenous (IV) iron has been shown to cause renal damage. The effect of IV iron on RRF has not been studied. Here, we report our experience during April 1999-March 2005 of the effect of IV iron on RRF. The study group included 24 patients (9 men, 15 women). The mean age of the group was 61 +/- 17.7 years. Diabetes mellitus and hypertension were the underlying cause of end-stage renal disease in 55% of the patients. We found serum creatinine, creatinine clearance, urea clearance, urine output, hemoglobin, transferrin saturation, and ferritin all to be statistically significantly different before and after administration of IV iron to the patients. However, the rate at which the glomerular filtration rate (GFR) declined over time did not change significantly when calculated for the period before and after the iron infusion, suggesting that the changes we observed after IV iron infusion were the result of the declining RRF--the rate of that decline being unaffected by the IV iron. Furthermore, the rate of GFR decline in this study was similar to that previously reported in our patients.

Background: Metabolic acidosis is a major metabolic abnormality in end-stage renal disease (ESRD) and alkali is provided with dialysis treatment to patients on chronic peritoneal dialysis (CPD) to keep their acid-base balance within normal serum HCO3- levels., Methods and Results: We examined the levels of venous serum HCO3- in 163 patients on CPD and the predictive factors for HCO3- levels low enough to indicate metabolic acidosis. The mean value for HCO3- was 26+/-2.4 mmol/l and for anion gap was 13.1+/-3.1 mEq/l. A serum bicarbonate concentration of less than 24 mmol/l, compatible with metabolic acidosis, was observed in 13.5% of the patients. In a multivariate analysis HCO3- levels were directly correlated with older age and use of CaCO3- as phosphate binders, and inversely associated with serum potassium, the use of sevelamer and low lactate dialysis solutions. Higher serum urea levels, the use of low lactate solutions and sevelamer instead of CaCO3 were significantly predictive factors for HCO3- levels < 24 mmol/l., Conclusions: Venous HCO3- and anion gap values were within the normal ranges in stable CPD patients. In 13.5% of them, however, chronic metabolic acidosis was observed based on venous HCO3- levels < 24 mmol/l. Dietary protein intake, the use of sevelamer and low (35 mmol/l) concentration of lactate in dialysis solutions are important predictive factors for chronic metabolic acidosis in these patients.

Objective: The purpose of this study (the third in a series of similar studies) is to evaluate the prevalence of Staphylococcus aureus (SA), methicillin-resistant SA (MRSA) and mupirocin-resistant SA (MuRSA) carriers in a peritoneal dialysis centre where patients have been instructed to use prophylactic mupirocin ointment at the catheter exit site over the last 7 years., Methods: Swabs were taken from catheter exit site, nares, axillae and groin in 147 chronic peritoneal dialysis out-patients between November 2003 and January 2004. Axillae/groin and nasal samples were pooled and cultured in the same medium, whereas exit site swabs were cultured separately. All SA isolated were tested for methicillin and mupirocin resistance using oxacillin screening plates and E-test strips., Results: Sixteen of 147 patients (10.9%) were found to be SA carriers: of these 13 (8.8%) had a positive nasal/axillae/groin culture; two (1.4%) had both nasal/axillae/groin- and exit site-positive culture; and one (0.7%) had only exit site-positive culture. In these 16 SA carriers, we found mupirocin-resistant strains (MuRSA) in four patients (25%) and MRSA in two patients (12.5%). Among the four MuRSA carriers, one had both nasal/axillae/groin- and exit site-positive culture and three had only nasal/axillae/groin-positive culture. Three high-level resistance and one low-level resistance MuRSA carriers were isolated. One MuRSA strain was also methicillin resistant. All MRSA strains were sensitive to vancomycin and rifampicin., Conclusion: After 7 years' routine use of prophylactic mupirocin ointment at the catheter exit site in non-selected chronic peritoneal dialysis patients, MuRSA was found in 25% of SA strains isolated or in 2.7% of the patients. Compared with our previous study, 3 years earlier, there is no significant increase in the MuRSA prevalence in peritoneal dialysis patients who routinely apply mupirocin ointment at the catheter exit site.

Objective: Patients on peritoneal dialysis (PD) can develop uremic symptoms as their residual renal function declines. In this retrospective study, we assessed the effect of increasing the dose of dialysis in patients who developed uremic symptoms., Methods: Patients on PD who had an increase in their dialysis dose due to either the appearance of uremic symptoms or to worsening biochemical parameters were included in this study. These patients had to have been on PD for at least 6 months before and after the increase in their dialysis dose. Patients whose dialysis dose was increased after the initial Adequest (done within 2-3 months of starting PD) findings or for reasons other than underdialysis were excluded from this study. The symptoms studied in 104 patients included fatigue, anorexia, insomnia, pruritus and nausea. The presence or absence of theses symptoms was evaluated before and after the increase in the dialysis volume. Several clinical and laboratory data including the adequacy results were compared before and after the increase in dialysis dose., Results: Patients were on PD for 24.6+/-16 months when dialysis dose was increased. Eighty-five (82%) of them were on continuous ambulatory peritoneal dialysis (CAPD) while the remaining were on continuous cycler peritoneal dialysis (CCPD). Fatigue was the most common symptom that led to an increase in the dialysis dose (64%). The prevalence of all the symptoms studied decreased significantly after the increase in dose of dialysis. The weekly peritoneal creatinine clearance increased from 47.35+/-0.88 to 57.34+/-1.401 (P < 0.0001) and the weekly Kt/V increased from 1.8+/-0.03 to 2.27+/-0.05 (P < 0.0001). The daily urine volume and the residual GFR decreased from 318.7+/-36.4 to 151.9+/-22.8 ml/day (P < 0.0001) and 2.05+/-0.2 to 0.82+/-0.12 ml/min (P < 0.0001) respectively during the study period., Conclusion: The prevalence of all uremic symptoms decreased significantly after the daily dialysate volume was increased. The improvement in symptoms despite the decline in residual function emphasizes the beneficial effect of increased dialysate volume, which produced a significantly higher peritoneal creatinine clearance and Kt/V after the change in the PD prescription.

Hernias can lead to significant morbidity in patients on peritoneal dialysis (PD). We studied the natural history and outcome of incarcerated hernia (IH), with or without bowel strangulation (IHS), in PD patients. We performed a retrospective chart review on all PD patients who developed an IH (n = 11) or an IHS (7/11) in the last 12 years. Of the 11 patients, 54% were female. The age range was 36 - 86 years (median: 61 years). Seven patients had a known history of a hernia that went on to become the index hernia that incarcerated with or without strangulation. The hernia types were umbilical (n = 8), inguinal (n = 2), and incisional in the area of the PD catheter (n = 1). Clinical presentations included painless abdominal mass (2 patients); tender and painful abdominal mass (4 patients); and abdominal pain, tenderness, and bowel obstruction (5 patients). Nine hernias were treated surgically--5 of them emergently for bowel ischemia. The other 4 patients who had incarcerated, non strangulated hernias were operated electively. One patient with IHS had the hernia manually reduced, and 1 patient with IHS had the hernia manually reduced and subsequently operated electively. Three patients with IHS and 2 with IH required temporary hemodialysis for between 4 days and 21 days. In PD patients, IHs are most commonly umbilical and have a propensity to strangulate. Patients treated operatively have an excellent prognosis and are usually able to continue PD. Abdominal wall hernias should be referred early to minimize mechanical complications.

Peritoneal dialysis (PD) has seldom been reported in patients developing end-stage renal disease (ESRD) after liver transplantation (LTx). Here we present our recent experience with PD in 5 such patients. Of the 5 patients, 3 were men and 2 were women. Average age at initiation of PD was 64.6 years (range: 54 - 72 years). Chronic renal failure (CRF) was diagnosed an average of 3.8 years (range: 1 - 7 years) post transplant and resulted in ESRD an average of 9.2 years (range: 6 - 15 years) after LTx. Calcineurin inhibitor toxicity was the presumed causative factor in all 5 patients, with biopsy confirmation in 2. All of the patients had hypertension at the time of diagnosis of CRF, 2 had coronary artery disease, and 1 developed diabetes mellitus. No patient had ascites before PD initiation. Peritoneal dialysis catheter implantation was uneventful in all patients. Average duration of follow-up was 13.6 months (range: 6 - 29 months). Three episodes of peritonitis occurred in 2 patients (coagulase-negative staphylococcus, Staphylococcus aureus, and Acinetobacter). All episodes of peritonitis responded to standard treatment. Clearance was found to be adequate in all but 1 patient. One patient died 19 months after initiation of PD. At the time of writing, the remaining 4 patients are alive on PD after an average of 12.2 months (range: 6 - 29 months). We conclude that PD is a viable and safe option for managing ESRD that develops after LTx.

In this retrospective study we present our experience with chronic peritoneal dialysis in nine patients with ESRD in their 10th decade of life (> or =90 years) at the Toronto Western Hospital. A family member or a private nurse assisted all patients in dialysis procedure. The co-morbid illnesses, survival, hospitalizations and complications related or unrelated to peritoneal dialysis were reviewed. Four patients started dialysis before and five after their 90th birthday, their mean age was 90.61+/-4.04 years. All patients had three or more co-morbid illnesses at the start of dialysis. Total duration of PD treatment was 210 patient months with a median duration of 25 months (range 4-68 months). Of the nine patients, four died after a mean follow up of 38.5 months on dialysis. Of the remaining five, one was transferred to hemodialysis after remaining for 10 months on peritoneal dialysis and the other four are continuing on PD for a mean duration of 9.25 months. Peritonitis (1/13.4 patient months) and exit site infection (1/100.5 patient months) responded to treatment. Hospitalization rate was one admission per 2.5 patient years. Most often, the cause of hospitalization was unrelated to PD, e.g., cardiovascular events, pneumonia and peripheral vascular disease etc. Patient survival at 1, 3 and 5 years was 88%, 58% and 24% respectively. The technique survival was 69%, 47% and 23% at 1, 3 and 5 years respectively. We conclude that continuous peritoneal dialysis is a safe and suitable treatment even in nonagenarians (> or =90 years) ESRD patients.

Purpose of Review: This review examines the results of the ADEMEX (Adequacy of Peritoneal Dialysis in Mexico) study in the context of other recent advances in peritoneal dialysis, and assesses the implication of this new knowledge for the optimal peritoneal dialysis prescription., Recent Findings: The prospective randomized controlled ADEMEX study demonstrated no survival advantage of an increased dose of peritoneal small molecule clearance delivered by chronic ambulatory peritoneal dialysis. Coincident with this finding, there has been increasing awareness that many peritoneal dialysis patients are volume expanded, and that there are adverse cardiovascular consequences to this chronic overhydration. As a result there has been a shift away from interest in peritoneal small solute clearance with renewed interest in peritoneal removal of salt and water. There is also increasing evidence of the importance of residual renal function in maintaining euvolemia and as a prognostic indicator for survival., Summary: The ADEMEX study and subsequent investigations have changed the way we perceive the optimal peritoneal dialysis prescription. This has resulted in de-emphasis of peritoneal small molecule clearance and increased emphasis on clinical assessment of dialysis adequacy, preservation of residual renal function, and optimization of salt and water removal.

Background: A multidisciplinary approach has been shown to be of benefit in the prevention of lower limb ulceration and amputation in patients with diabetes, but there is less information on the role of such an approach in patients receiving dialysis treatment., Objective: The purpose of the present study was to determine whether the institution of a chiropody program would result in fewer amputations in diabetic patients on peritoneal dialysis (PD)., Design: Retrospective chart review., Setting: The PD program at a tertiary-care hospital., Patients: Patients with diabetes that were enrolled in the PD program between January 1997 and December 1999, inclusive, that were offered the opportunity to see a chiropodist, and that agreed to be seen. A total of 132 patients were included., Intervention: Education about foot care, assessment, and, in some instances, treatment by a chiropodist., Results: Patients with an amputation were more likely to be male (p < 0.01) and have peripheral vascular disease (p < 0.001) compared to those without an amputation. They also had a lower average mean arterial pressure (p < 0.05), lower weekly creatinine clearance (p < 0.01), higher mean erythropoietin dose (p < 0.05), and longer duration of end-stage renal disease (p < 0.001). Factors that were predictive of shorter time to death or amputation were older age [hazard ratio (HR) = 1.03, p < 0.05], peripheral vascular disease (HR = 2.66, p< 0.01), and cerebrovascular disease (HR = 2.70, p< 0.01). Being seen by a chiropodist was protective (HR = 0.39, p < 0.01)., Conclusion: The current study suggests that a chiropody program may help to prevent amputation in patients with diabetes on PD.