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Many studies have examined the survival of the first peritoneal dialysis (PD) catheter. However, data are scarce about the factors that influence the function and survival time of a second PD catheter. The purpose of the present study was to calculate the survival time of the second PD catheter and to examine factors that predict removal of that catheter. We conducted a retrospective study of second PD catheters inserted at our institution over a 10-year period from May 1992 to April 2002. The endpoint consisted of removal of the second catheter. Voluntary change to hemodialysis, kidney transplantation, transfer to another center, and death with a functioning catheter were censored observations. Catheter survival was analyzed by the Kaplan-Meier method. During the study period, 106 patients (59 men, 47 women) received a second catheter. The mean age of the patients was 55 +/- 14.9 years. One third of the patients had diabetes. The reasons for removal of the first catheter and insertion of the second one were peritonitis (n = 50), catheter malfunction (n = 20), catheter leak (n = 11), exit site or tunnel infection (n = 21), and failed kidney transplantation with resumption of PD (n = 4). The median survival of the second catheter was 48 months (95% confidence interval: 38 months to 59 months). On univariate analysis, increasing patient age and peritonitis as cause for removal of the first catheter were associated with an increased risk of removal of the second catheter. However, on multivariate analysis, only increasing patient age was associated with a greater risk to survival of the second catheter.

Background: Sexual dysfunction including erectile dysfunction (ED) is common in patients with end stage renal disease on peritoneal dialysis (PD). Prevalence and determinants of ED in these patients has not been well characterized., Patients and Methods: Prevalence of ED in 44 patients on chronic PD was assessed using the International Index of Erectile Function (IIEF-5) commonly called Sexual Health Inventory for Men (SHIM) score. The associations between ED and other medical conditions was also assessed., Results: Prevalence of ED was high at 88%. Mean age of all patients was 61.8 +/- 13.9 years. Thirty-two patients were hypertensive, 19 of them had coronary artery disease and 13 patients were diabetics. All patients with diabetes had ED. Age and diabetes were found to be significantly associated with ED., Conclusion: ED is highly prevalent in patients on chronic PD. Increasing age and diabetes were associated with higher percentage of ED.

Renal cell carcinoma is a rare but serious complication in ESRD patients. In these patients the incidence of renal cell carcinoma (RCC) is 20-40 times higher than in the general population. We performed a retrospective study to measure the incidence rate, prevalence, characteristics and survival among our peritoneal dialysis (PD) patients diagnosed with renal cell carcinoma. The study was carried out among 607 patients who were on the PD program from January 1997 to June 2002. RCC was detected in eight patients (four males and four females) with mean age of 52.1 +/- 10.6 years. Among these eight patients four were new cases that were diagnosed before the patients were started on dialysis (three in native kidneys and one in a transplanted kidney). In the other four patients the RCC was diagnosed after they had been on dialysis for 33-204 months (mean 60.75 +/- 50.48). We found an incidence rate of 1.3 per 1000 patients per year and a prevalence of 1.3%. Six of the eight patients had renal cysts. Tumor size was less than 7 cm in seven patients and in the other patient it was 8.5 cm. Seven of eight patients were alive at the time of study with a survival time ranging from 3-138 months (mean 122.25 +/- 88.2) months. In one patient, the RCC metastasised to the scalp, and, in two other patients, the tumors subsequently involved the second kidney. A cardiovascular complication was the cause of one death. Two patients received a renal transplant 36 and 66 months after diagnosis. We conclude that despite the low rate of metastases and mortality in our study, regular ultrasonography should be added to the follow-up of PD patients. Renal transplantation can be considered in these ESRD patients with RCC; however, close follow-up for metastases is recommended.

Fatigue is a common complaint in long term dialysis patients that may influence their quality of life. The present study was carried out in order to evaluate the prevalence and course of fatigue in a group of chronic PD patients and to find the possible factor(s) related to its development. We retrospectively reviewed 100 charts of the patients previously on PD. The presence or absence of fatigue in the 1st and last clinic visits and the 1st and 2nd changes in fatigue state were studied according to the monthly clinical records of the primary nurses. Data regarding dialysate volume, urine volume, weekly erythropoietin (EPO) dose, hemoglobin, hematocrit, blood urea, serum creatinine, residual renal creatinine and urea clearances, dialysate to peritoneal creatinine ratio (D/P Cr), total weekly Kt/V and total creatinine clearance/1.73 m2 body surface area (TCrCl) were collected. Fifty-five patients were male and 45 female. The mean age at the 1st clinic visit was 61.3 +/- 16 years. At the 1st visit 55 patients had fatigue and 45 did not. In 32 of the 55 patients fatigue disappeared after a mean duration of 7.9 +/- 8.4 months and in 31 of the 45 patients fatigue appeared after a mean duration of 8 +/- 6.8 months. So at the last visit the frequency of fatigue increased significantly from 55% to 67% (p < 0.001). In patients with fatigue the mean age and female percentage were higher (64.2 +/- 14.1 vs 57.8 +/- 17.6, p = 0.05 and 1.2 vs 0.5, p < 0.05 respectively), mean hemoglobin concentration was lower (104.4 +/- 14.7 vs 110.6 +/- 14.2 g/L, p < 0.04) and mean EPO dose was higher (6379.6 +/- 7142 vs 3395.4 +/- 4337.8 units/week, p < 0.02) at the 1st clinic visit. EPO dose was also higher in patients with fatigue at the last visit (8253.7 +/- 10317.3 units/wk vs 4736.4 +/- 5432.5, p < 0.03). No correlation was found between dialysis adequacy according to either weekly Kt/V or TCrCl and nutritional state according to nPCR and frequency of fatigue. We conclude that fatigue is a common symptom in PD patients and it's prevalence increases over time. Anemia seems to be the most important factor associated with fatigue. Dialysis adequacy and nutritional state did not show any correlation with the frequency of fatigue in our study.

Purpose of Review: This review examines recent developments in the understanding of the effect of conventional, bioincompatible peritoneal dialysis fluids on structural and functional changes in the peritoneal membrane. Emphasis is placed on the clinically relevant outcome of failure of long-term peritoneal dialysis. Therapeutic strategies to prevent technique failure, including the use of new peritoneal dialysis fluids and continuous flow peritoneal dialysis, are explored., Recent Findings: Long-term (greater than 6 months) exposure to new peritoneal dialysis fluids with physiologic pH, lower lactate concentrations, or lower concentrations of glucose degradation products results in improved leukocyte cytokine release, ultrafiltration, and mesothelial cell mass, respectively. Continuous flow peritoneal dialysis allows efficient small molecule removal using dialysate with lower glucose concentration and possibly less glucose degradation products. Recent technical advances include creation of a double-lumen peritoneal dialysis catheter, and methods of monitoring intra-abdominal pressure and ultrafiltration., Summary: Though initial reports with biocompatible peritoneal dialysis fluids are promising, the efficacy of these new solutions in preventing long-term peritoneal dialysis failure is unproven. Conditions in which new peritoneal dialysis fluids may be beneficial are suggested. Continuous flow peritoneal dialysis requires substantial technical improvements before this technique can be widely accepted.

Objective: No studies have been done to examine factors that predict the outcome of bacterial peritonitis during peritoneal dialysis (PD), beyond the contribution of the organism causing the peritonitis, concurrent exit-site or tunnel infection, and abdominal catastrophes., Design: In this study we examined several clinical and laboratory parameters that might predict the outcome of an episode of bacterial peritonitis. Between March 1995 and July 2000, we identified 399 episodes of bacterial peritonitis in 191 patients on dialysis., Results: There were 260 episodes of gram-positive peritonitis, 99 episodes of gram-negative peritonitis, and 40 episodes of polymicrobial peritonitis. Gram-positive peritonitis had a significantly higher resolution rate than either polymicrobial peritonitis or gram-negative peritonitis. Staphylococcus aureus episodes had poorer resolution than other gram-positive infections. Nonpseudomonal peritonitis had a better outcome than Pseudomonas aeruginosa episodes. Among all the gram-negative infections, Serratia marcescens had the worst outcome. Episodes associated with a purulent exit site had poor outcome only on univariate analysis. For those peritonitis episodes in which the PD fluid cell count was > 100/microL for more than 5 days, the nonresolution rate was 45.6%, compared to a 4.2% nonresolution rate when the cell count returned to 100/microL or less in less than 5 days. Those patients that had a successful outcome had been on continuous ambulatory PD for a significantly shorter period of time than those patients that had nonresolution. The nonresolution rate for those patients that had been on PD for more than 2.4 years was 24.4%, compared to 16.5% for those that had been on PD for less than 2.4 years (p = 0.05)., Conclusion: The duration of PD and the number of days the PD effluent cell count remained > 100/microL were the only factors that independently predicted the outcome of an episode of peritonitis. Caucasians seem to have a higher nonresolution (failure) rate compared to Blacks. Other variables, such as the number of peritonitis episodes before the episode in question, vancomycin-based initial empiric treatment, serum albumin level, total lymphocyte count and initial dialysate white blood cell count, age, sex, diabetes, previous renal transplantation, and the use of steroids did not affect the outcome of peritonitis.

Background: Patient survival is prolonged in those with residual renal function. The risks of opportunistic infection and malignancy militate against a widespread policy of maintaining immunosuppression in those returning to peritoneal dialysis after a failed allograft. We set out to test the hypothesis that patients returning to peritoneal dialysis after a failed transplant benefit from continued immunosuppression., Method: A decision analytic model comparing the use of immunosuppression after transplant failure and return to peritoneal dialysis with immunosuppressive withdrawal. Two assumptions were made: that the survival benefit reported in patients with a transplant kidney was the same as that expected from a native kidney with a similar glomerular filtration rate (GFR) and that the risks of carcinoma and opportunistic infections were equal to that of the general population if immunosuppressive therapy was discontinued. Probabilities were obtained from the literature, from an administrative database, and from the rate of GFR decline seen in our own unit in patients returning to dialysis who had been discontinued from their transplant immunosuppressive medication., Results: Life expectancy was prolonged from 5.3 years to 5.8 years when immunosuppression was continued in patients who returned to dialysis after chronic allograft failure. A higher survival benefit was seen at higher levels of additional GFR. A benefit from continued immunosuppressive therapy was seen for all values of additional GFR greater than 15 L/wk. All dialysis and renal clearances have been expressed as L/wk. The conversion factors for conversion to mL/s and mL/min are 605 and 10.1., Conclusion: The data suggest that there may be a survival advantage in maintaining patients on long-term immunosuppressive function even after they return to peritoneal dialysis after allograft failure., (Copyright 2002 by the National Kidney Foundation, Inc.)

This article reports the case of a 33-year-old woman with common variable immunodeficiency (CVI) who developed renal failure 17 years after diagnosis and initiation of treatment with monthly IVIG. A renal biopsy revealed mesangial and paramesangial immune complex deposition and interstitial granulomatous infiltration. Renal function improved with oral corticosteroids, but did not return to normal. Decreasing the dose of IVIG had no effect on renal function. Immune dysfunction can be associated with both granulomatous disease and immune complex glomerulonephritis, or the latter may be related to chronic infection or immunoglobulin use. This is the first report of concomitant glomerular-tubulointerstitial lesions in this immunodeficiency syndrome. Renal function should be closely followed in patients with CVI.

Background: Hypertension is the prime contributor for cardiovascular mortality in the dialysis population. Peritoneal dialysis (PD) has been thought to improve blood pressure (BP) control in the short term, but the long-term benefits are not conclusively proven. We aimed to evaluate the degree of BP control in PD patients in the long term and analyse the factors associated with poor control., Methods: Data of all patients who were initiated on PD at one centre between July 1994 and July 1998 and completed at least 1 year of PD were analysed retrospectively at initiation of PD, at 6 months, and annually thereafter until 5 years or until discontinuation of therapy. Hypertension was defined as per WHO/ISH criteria. A 'Blood Pressure Control Index' was empirically defined to account for the effect of antihypertensives on measured BP. Factors associated with poor BP control were analysed., Results: Out of 207 patients (age 57.0+/-16.0 years, 103 male, 104 female) 91.3% were hypertensive at the start of PD. About 33.8% had diabetic nephropathy. Systolic and mean arterial pressure index improved in early phase reaching a nadir between 6 months and 1 year followed by steady progressive worsening through out the rest of follow up. On multiple linear regression analysis age (P<0.001), duration of hypertension prior to dialysis (P<0.001), and declining residual renal function, expressed as both average of urea and creatinine clearance (P=0.002) and residual urine output (P<0.001) were independently associated with poor BP control. Diabetes (P=0.836), peritoneal transport (D/P 4 of creatinine at start) (P=0.218), peripheral oedema (P=0.479) and dose of erythropoetin (P=0.488) were not associated., Conclusions: Initiation of PD results in early improvement of hypertension in end-stage renal disease (ESRD). BP control thereafter deteriorates steadily with time and this is associated with age, duration of hypertension, and declining residual renal function. This suggests that hypertension in ESRD patients is a progressive disease primarily related to falling glomerular filtration rate, the preservation of which might improve BP control and possibly modify cardiovascular risk.

Objective: To determine the prevalence of the carriage of Staphylococcus aureus (SA), methicillin-resistant Staphylococcus aureus (MRSA), and mupirocin-resistant Staphylococcus aureus (MuRSA) in chronic peritoneal dialysis (CPD) patients after 4 years of prophylactic mupirocin application to the exit site, in a peritoneal dialysis unit., Methods: Three swabs were collected from the nares, axillae/groin, and exit site, respectively, from 149 patients on CPD between May and July 2001. All swabs were cultured on solid selective agar (mannitol salt agar) and in mannitol salt broth. Staphylococcus aureus isolates were tested for methicillin resistance using oxacillin screening plates, and mupirocin resistance using E-test strips. Low-level MuRSA was defined as minimum inhibitory concentration (MIC) of 4 mg/mL or more, and high-level MuRSA as MIC of 256 mg/mL or more., Results: Staphylococcus aureus was isolated from 26 (17%) patients (25 from nares/axilla/groin, and 1 from the exit site). High-level MuRSA was isolated from 4 patients (3% of the total study population; 15% of total SA isolates). No MRSA was detected. One patient with high-level MuRSA had peritonitis due to SA, resulting in treatment failure and catheter loss, soon after the swabs were collected for the study., Conclusion: We report the emergence of high-level MuRSA in CPD patients after a 4-year practice of continuous use of mupirocin in a small number of patients in our unit. Our results may have significant implications for the future practice of prophylactic use of mupirocin by CPD patients to prevent exit-site infection.

Studies of the adequacy of peritoneal dialysis and recommendations have assumed that renal and peritoneal clearances are comparable and therefore additive. The CANUSA data were reanalyzed in an effort to address this assumption. Among the 680 patients in the original CANUSA study, 601 had all of the variables of interest for this report. Adequacy of dialysis was estimated from GFR (mean of renal urea and creatinine clearance) and from peritoneal creatinine clearance. The Cox proportional-hazards model was used to evaluate the time-dependent association of these independent variables with patient survival. For each 5 L/wk per 1.73 m(2) increment in GFR, there was a 12% decrease in the relative risk (RR) of death (RR, 0.88; 95% confidence interval [CI], 0.83 to 0.94) but no association with peritoneal creatinine clearance (RR, 1.00; 95% CI, 0.90 to 1.10). Estimates of fluid removal (24-h urine volume, net peritoneal ultrafiltration, and total fluid removal) then were added to the Cox model. For a 250-ml increment in urine volume, there was a 36% decrease in the RR of death (RR, 0.64; 95% CI, 0.51 to 0.80). The association of patient survival with GFR disappeared (RR, 0.99; 95% CI, 0.94 to 1.04). However, neither net peritoneal ultrafiltration nor total fluid removal was associated with patient survival. Although these results may be explained partly, statistically, by less variability in peritoneal clearance than in GFR, the latter seems to be physiologically more important than the former. The assumption of equivalence of peritoneal and renal clearances is not supported by these data. Recommendations for adequate peritoneal dialysis need to be reevaluated in light of these observations.

Background: Early renal transplant failure necessitating a return to dialysis has been shown to be a poor prognostic factor for survival. Little is known about the outcome of patients with late transplant failure returning to dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients returning to dialysis., Objective: To determine whether patients with a failed renal transplant have an outcome different to those on dialysis who have never received a kidney transplant., Setting: Peritoneal dialysis (PD) unit in a teaching hospital., Patients and Design: All failed renal transplant patients (fTx) in the Toronto Hospital Peritoneal Dialysis program between 1989 and 1996 were identified. This cohort of 42 fTx patients was compared with a cohort of randomly selected never-transplanted PD patients (non-Tx). The PD program was selected because of the availability of well-documented patient archival material. The non-Tx group was matched for age and presence of diabetes. Data were collected until retransplantation, change of dialysis modality or center, death, or until June 1998., Results: There was no difference at initiation of PD between groups in serum albumin, residual renal function, or mean serum parathyroid hormone level. The mean low-density lipoprotein level was significantly higher in the fTx cohort. The duration of dialysis before Tx in fTx patients accounted for the increased total length of dialysis in fTx (mean 15 months). However, post-Tx the duration of PD was similar for both groups (30.7 months for fTx vs 31.6 months for non-Tx). The fTx group had a considerably worse outcome than the non-Tx group. The time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a much faster rate in fTx patients. The most dramatic difference was in survival. There were 3 deaths in the non-Tx group and 12 in the fTx group (p < 0.01). The mean age at time of death in the fTx group was 47.5 years. Deaths were due mainly to gram-negative peritonitis and cardiovascular disease., Conclusions: We conclude that late failed renal transplant patients starting dialysis are at increased risk of complications and have strikingly higher mortality rates than non-Tx patients. A previously failed kidney transplant can be considered an adverse prognostic factor for patients commencing PD; these patients need to be closely monitored. Although this study was limited to PD patients, the same principles likely apply to fTx patients returning to any form of renal replacement therapy.

Background: Fibric acid derivatives (fibrates) are commonly used for the treatment of hyperlipidemia. A side-effect of these medications that is not well recognized is deterioration in renal function during therapy. This study reviewed a series of patients who showed such a deterioration., Methods: The design was a retrospective chart review. Data extracted included creatinine, urea, cyclosporine levels, medical history, and medications. Charts were examined for other potential reasons for a change in creatinine., Results: There were a total of 10 patients. All were males between the ages of 37 and 71. All had a history of renal insufficiency. Six had received a renal transplant and, of these, 5 were on cyclosporine. Reasons for underlying renal impairment included diabetes, hypertension, nephrosclerosis, and renal disease of unknown etiology. Most patients had risk factors for or the presence of vascular disease. The mean pre-treatment creatinine was 182 +/- 14 micromol/l (2.1 +/- 0.2 mg/dl) (mean +/- SE), compared to a peak creatinine on the medication of 247 +/- 16 micromol/l (2.8 +/- 0.2 mg/dl) (p < 0.001). The post-medication mean was 183 +/- 13 (2.1 +/- 0.1 mg/dl) (p < 0.001 vs maximum creatinine). Urea values also increased with therapy and decreased following discontinuation of the fibrate. Cyclosporine levels did not change with treatment. All recorded creatine kinase values were within the normal range., Conclusions: A group of 10 men showed a reversible deterioration in renal function while being treated with a fibrate for hyperlipidemia. The mechanism involved in the deterioration in renal function is not clear. The most plausible mechanism is one based on renal hemodynamics, given the rapid and complete reversibility that was noted and the finding that most patients had risk factors for vascular disease. If patients with pre-existing renal dysfunction are to receive a trial of fibrate therapy, this should be done with caution and

Three recent studies using registry data from the United States, in comparing the mortality risks between peritoneal dialysis (PD) and hemodialysis (HD), have consistently found that elderly diabetic women on PD have a higher mortality risk as compared with their counterparts on HD. Though the cause for this observation is not clear, the phenomenon may be unique to the United States. Alternatively, a selection bias impossible to decipher may be at work in these studies, as none of them have data on comorbidity, nutrition, or adequacy of dialysis. Finally, the possibility that elderly diabetic women are, for some reason, more vulnerable to the ill effects of peritoneal dialysis should be considered. We report here a retrospective analysis of 47 diabetic women, above 55 years of age, with end-stage renal disease, who were started on PD and who later died on dialysis. The primary outcome of interest was cause of death. Demographic details about the patients, comorbid conditions, dialysis adequacy, and biochemical parameters at the start of PD were noted. Death in these patients was attributed mainly to vascular causes, and there appeared to be a high prevalence of peripheral vascular disease. Infection was the next major cause of death, being the primary cause in 14 patients. Of these, only 5 patients had peritonitis. On a Cox regression analysis, only patient age and duration of diabetes at onset of dialysis were found to be predictive of vascular death. No factor was found to be predictive of death from infection. It appears that elderly diabetic women on PD die mainly of the long-term complications of diabetes.

Objective: We analyzed residual renal function (RRF) in a large number of new peritoneal dialysis (PD) patients to prospectively define the time course of decline of RRF and to evaluate the risk factors assumed to be associated with faster decline., Study Design: Single-center, prospective cohort study., Setting: Home PD unit of a tertiary care University Hospital., Patients: The study included 242 patients starting continuous PD between January 1994 and December 1997, with a minimum follow-up of 6 months and at least three measurements of RRF., Measurement: All patients had data on demographic and laboratory variables, episodes of peritonitis and the use of aminoglycoside (AG) antibiotics, temporary hemodialysis, and number of radiocontrast studies. Adequacy of PD was measured from 24-hour urine and dialysate collection and peritoneal equilibration test using standard methodology. Further data on RRF was collected every 3 to 4 months until the patient became anuric (urine volume < 100 mL/day or creatinine clearance < 1.0 mL/min) or until the end of study in December 1998., Outcome Measure: The slope of the decline of residual glomerular filtration rate (GFR) (an average of renal urea and creatinine clearance) was the main outcome measure. Risk factors associated with faster decline were evaluated by a comparative analysis between patients in the highest and the lowest quartiles of the slopes of GFR, and a multivariate analysis using a stepwise option within linear regression and general linear models., Results: There was a gradual deterioration of residual GFR with time on PD, with 40% of patients developing anuria at a mean of 20 months after the initiation of PD. On multivariate analysis, use of a larger volume of dialysate (p = 0.0001), higher rate of peritonitis (p = 0.0005), higher use of AG (p = 0.0006), presence of diabetes mellitus (p = 0.005), larger body mass index (BMI) (p = 0.01), and no use of antihypertensive medications (p = 0.04) independently predicted the steep slope of residual GFR. Male gender, higher grades of left ventricular dysfunction, and higher 24-hour proteinuria were associated with faster decline on univariate analysis only., Conclusion: Faster decline of residual GFR corresponds with male gender, large BMI, presence of diabetes mellitus, higher grades of congestive heart failure, and higher 24-hour proteinuria. Higher rate of peritonitis and use of AG for the treatment of peritonitis is also associated independently with faster decline of residual GFR. Whether the type of PD (CAPD vs CCPD/NIPD) is associated with faster decline of residual GFR remains speculative.

Multiple myeloma is associated with a wide array of renal diseases that include myeloma cast nephropathy, monoclonal immunoglobulin deposition disease, amyloidosis, cryoglobulinemia, tubular dysfunction, pyelonephritis, nephrocalcinosis, urate nephropathy, and infiltration by atypical plasma cells (or myeloma cells). Filtered immunoglobulin light chains may affect both the distal and, more frequently, the proximal tubule. Tubular abnormalities in patients with plasma cell dyscrasia may be more frequent than previously thought. A patient with a plasma cell dyscrasia is described, who presented with biochemical features consistent with Fanconi syndrome. Immunoelectron microscopy performed on the renal biopsy confirmed the presence of kappa light chain immunoglobulin in intracytoplasmic crystals in proximal tubular epithelial cells. This report is one of a few demonstrating the presence of light-chain immunoglobulin in intratubular crystals in a human renal biopsy obtained from a patient with a plasma cell dyscrasia and Fanconi syndrome.

Objective: To evaluate the effectiveness of total parathyroidectomy (PTX) with autotransplantation in the treatment of secondary hyperparathyroidism (HPT), and to assess recurrence rate of HPT in this peritoneal dialysis (PD) population., Design: A retrospective study in a single home PD unit., Patients: Between 1994 and 1998, 19 of 574 patients on PD underwent PTX for treatment of secondary HPT., Main Outcome Measures: Clinical and biochemical improvement, recurrence of HPT, improvement in anemia post-PTX., Results: Nineteen (3.3%) patients required PTX between 1994 and 1998. These 5 men and 14 women ranged in age from 22 to 66 years; they had been on maintenance PD pre-PTX for 47.5 +/- 38.1 months, and were followed for 26.1 +/- 15.5 months post-PTX. Sixteen patients had temporary hypocalcemia that was managed by oral (n = 10) or intravenous (n = 6) calcium supplements and calcitriol, while 3 patients had severe "hungry bone" syndrome postoperatively. One patient had recurrent laryngeal nerve palsy post-PTX. Bone pain disappeared in all 12 patients. Pruritus improved in 12/13 patients; fatigue improved in 15/16 patients. Comparison showed significant differences between hemoglobin and hematocrit values 1 month pre-PTX and 12 months post-PTX (p < 0.05). Parathyroid hormone (PTH) level in 15 (79%) patients returned to normal (< or = 7.6 pmol/L) during the first month post-PTX. In 5/12 (42%) patients, PTH level was < or = 7.6 pmol/L 2 years post-PTX, while in 2/12 (17%), PTH was > 22.8 pmol/L (three times normal) 2 years post-PTX, and 3/5 (60%) patients had a PTH > 22.8 pmol/L 3 years post-PTX., Conclusions: Total PTX with autotransplantation is associated with a tendency for recurrence of HPT. Our findings suggest that total PTX with autotransplantation may be an ineffective procedure in controlling HPT over the long term.

Objective: Primarily, to determine whether peritoneal small solute clearance is related to patient and technique survival among anuric peritoneal dialysis [continuous ambulatory (CAPD) and automated peritoneal dialysis (APD)] patients. A secondary goal was to describe the ability to attain Dialysis Outcomes Quality Initiative (DOQI) targets among anuric patients on peritoneal dialysis., Design: Retrospective cohort study via chart reviews., Setting: Peritoneal Dialysis Unit of Toronto Hospital (Western Division)., Patients: The study included 122 CAPD and APD patients between January 1992 and September 1997, with 24-hour urine volume less than 100 mL, or renal creatinine clearance (CCr) less than 1 mL/minute. Adequacy data were available for 115 patients., Outcome Measures: Mortality and technique failure (TF). Regression analysis was used to estimate the mortality and TF rate ratios (RR) for peritoneal Kt/V urea (pKt/V) and pCCr, adjusting for age, gender, diabetes, months of follow-up prior to anuria, albumin, transport status, coronary artery disease, cardiovascular disease, and peripheral vascular disease., Results: Fifty seven per cent (51/89) of patients on CAPD and 81% (21/26) on APD had a weekly pKt/V > or = 2 and > or = 2.2, respectively (DOQI targets); whereas only 35% on CAPD (31/89) and 35% (9/26) on APD had a weekly pCCr > or = 60 U1.73 m2 and 66 L/1.73 m2, respectively. Median follow-up times among patients were 16.5 and 19.5 months pre- and postanuria, respectively. Patients with pKt/V > or = 1.85 experienced a strong decrease in patient mortality (RR = 0.54, p= 0.10); the effect was less pronounced for pCCr > or = 50 L/1.73 m2 (RR = 0.63, p = 0.25). No relationship was observed between pKt/V or pCCr and TF., Conclusion: Mortality was noticeably less frequent among patients with a pKt/V > or = 1.85 compared with those with a Kt/W < 1.85 (p = 0.10). Given the magnitude of the association, the failure to observe statistical significance relates to the size of the patient cohort. Our results imply that it is, in fact, possible to achieve DOQI targets among anuric patients on peritoneal dialysis.

Recent evidence suggested that noncompliance (NC) with continuous ambulatory peritoneal dialysis (CAPD) exchanges may be more common in US than in Canadian dialysis centers. This issue was investigated using a questionnaire-based method in 656 CAPD patients at 14 centers in the United States and Canada. NC was defined as missing more than one exchange per week or more than two exchanges per month. Patients were ensured of the confidentiality of their individual results. Mean patient age was 56 +/- 16 years, 52% were women, and 39% had diabetes. The overall admitted rate of NC was 13%, with a rate of 18% in the United States and 7% in Canada (P < 0.001). NC was more common in younger patients (P < 0.0001), those without diabetes (P < 0.001), and employed patients (P < 0.05). It was also more common in black and Hispanic than in Asian and white patients (P < 0.001). NC was more common in patients prescribed more than four exchanges daily (P < 0.0001) but was not affected by dwell volume. On multiple regression analysis, the independent predictors of NC, in order of importance, were being prescribed more than four exchanges per day, black race, being employed, younger age, and not having diabetes. Being treated in a US unit did not quite achieve significance as a multivariate independent predictor. These findings suggest that NC is not uncommon in CAPD patients and is more frequent in US than in Canadian patients. However, country of residence is less powerful as a predictor of NC than a variety of other demographic and prescription factors.

Chronic renal failure can be considered an immunosuppressed state. One immunologic function that may be compromised is tumor surveillance. Studies have suggested an incidence of cancer that is greater in dialysis patients that in the age- and sex-matched non dialysis population. A drawback to many previous studies is "ascertainment bias," wherein closely monitored populations have a higher rate of cancer detection. However, allowing for systematic bias, a true increase in neoplasia appears to exist in dialysis patients. While many agencies have established protocols for cancer screening in the general population, little has been written about recommendations for cancer screening in dialysis patients. Moreover, the high mortality from cardiovascular disease may render cancer screening protocols redundant and cost-ineffective. This article offers recommendations that emphasize that risk profile of individual patients rather than a population-based approach to cancer screening.

Calciphylaxis is a rare and severe calcification syndrome described mainly in patients with end-stage renal disease (ESRD) undergoing dialysis or with a renal transplant. This life-threatening condition is characterized by the abrupt onset of painful ischemic skin ulcers and necrosis. Secondary local and systemic infection may supervene and, without timely and appropriate interventions, calciphylaxis may be fatal. A precipitant or challenging agent is believed to be necessary to initiate the process. We describe a case of a woman with ESRD receiving continuous ambulatory peritoneal dialysis who developed calciphylaxis in the setting of severe hyperparathyroidism after receiving UV photoradiation therapy. We suggest that the UV light served as the challenging agent in the precipitation of this devastating condition.

The treatment of idiopathic minimal lesion disease in children has been extensively studied in randomized controlled trials, however, there is less information available for adults. This article summarizes evidence-based recommendations for management. The first attack should be treated with prednisone or prednisolone at 60 mg/m2 per day (up to a maximum of 80 mg/day) for four to six weeks, followed by 40 mg/m2 of prednisone every other day for another four to six weeks (grade A). Relapse should be treated with 60 mg/m2/day of prednisone (up to 80 mg/day) only until the urine becomes protein free for three days, and then an alternate day regimen of 40 mg/m2 should be used for another month (grade A). Patients with frequently relapsing disease will have a significant reduction in relapse frequency after eight weeks of an alkylating agent (grade A). Less rigorous studies have suggested benefit with long-term, alternate-day corticosteroid (grade D) or the antihelminthic agent levamisole (grade D). For patients with steroid-dependent disease, an 8- or 12-week course with cyclophosphamide can induce remission (grade D). In true steroid-resistant disease, observational studies have suggested that a course of cyclosporine may sometimes induce remission or restore steroid responsiveness (grade D). Large retrospective studies in adults suggest that therapeutic response is slower than in children, but adults experience fewer relapses and more prolonged remission.

A patient maintained on continuous ambulatory peritoneal dialysis with severe hyperparathyroidism received a cadaver renal transplant. In the weeks following the transplant there was dramatic biochemical resolution of parathyroid hyperfunction associated with intensive immunosuppressive therapy, but without sustained return of function of the transplant kidney. Tertiary hyperparathyroidism often resolves slowly with successful renal transplantation. There are no previous reports of spontaneous resolution of hyperparathyroidism as demonstrated by this patient. Possible mechanisms, including the role of cytolytic antirejection therapy, are discussed.

Objective: To evaluate the potential effectiveness of nystatin as prophylaxis for fungal peritonitis (FP) in patients on continuous ambulatory peritoneal dialysis (CAPD)., Design: This historically controlled study was designed to investigate the effectiveness of nystatin in the prevention of FP. For this purpose we compared the incidence of FP among 240 (new and prevalent) CAPD patients between January 1996 and November 1996 (period A) with its incidence in 240 new and prevalent CAPD patients in our program between January 1997 and November 1997 (period B) when nystatin prophylaxis was used. There were 2400 patient-months in each period. Nystatin (500,000 IU four times per day), was given orally at the beginning of other antibiotic therapy (usually for peritonitis) and continued for 5 days after the end of the antibiotic therapy., Results: During period A, 133 peritonitis episodes were recorded, and during period B, 99 episodes were recorded. Six episodes of FP were identified in over 2400 patient-months of period A, and 12 in over 2400 patient-months of period B. This difference was not statistically significant. Three episodes of antibiotic-related FP were seen in period A, and four in period B. The remaining episodes arose de novo, that is, unrelated to the use of antibiotics. We observed no side effects for nystatin., Conclusion: In CAPD patients the use of nystatin, a nonabsorbable antifungal agent, as prophylaxis in every instance of peritonitis or other indications for antibiotics, did not lower the incidence of fungal peritonitis.

Objective: To evaluate the validity of recommending coronary artery bypass grafting (CABG) in preparation for renal transplantation in asymptomatic peritoneal dialysis (PD) patients with evidence of reversible myocardial ischemia., Design: Retrospective review in a single PD unit., Participants: Ten asymptomatic PD patients who underwent CABG to be placed on the transplant list comprised the study group. Ten age-, sex-, and disease-matched PD patients who did not receive CABG were used as a comparison group., Measurements: Clinical outcome from 1990 to the present., Results: Only 1 patient in the study group has received a transplant. Seven patients (70%) have died or have been removed from the list because of comorbid illness. Only 2 patients are still on the waiting list., Conclusion: As a result of the long waiting time for cadaveric renal transplant and the high risk of interim development of comorbid disease, only a minority of patients come to transplantation. The presence of coronary disease is likely a surrogate for more generalized cardiac and vascular disease in this population. In light of these findings, the policy of prophylactic revascularization in asymptomatic dialysis patients in preparation for renal transplantation needs to be reconsidered.

Objective: To evaluate the potential effectiveness of the application of mupirocin ointment at the catheter exit site in preventing exit-site infection and peritonitis caused by Staphylococcus aureus (SA)., Design: This prospective, historically controlled study was done on 181 peritoneal dialysis patients treated between 1 November 1996 and 1 November 1997. They were instructed to apply mupirocin at the catheter exit site daily or three times per week at the conclusion of their exit-site care (Study 1). The patients were not screened to determine whether they were SA carriers. The group's historical control was the infection data from the previous year among these patients. A second group of 70 patients, who started using mupirocin within a month after catheter implantation (1996-1997), was compared with a historical group of 118 patients (controls) who were on continuous ambulatory peritoneal dialysis (CAPD) for 1 year after in-patient implantation without mupirocin, (1990-1995) (Study 2)., Results: In the group of 181 patients (Study 1), application of mupirocin at the exit site led to a significant reduction in SA exit-site infections--21 versus 3 episodes (0.11 vs 0.01 episodes/patient/year)--and a significant reduction of SA peritonitis--35 episodes in the year preceding mupirocin versus 11 episodes during the year of mupirocin treatment (0.19 vs 0.06 ep/pt/yr). The same results were observed in Study 2: the incidence of SA exit-site infection was significantly lower in the mupirocin-treated group--17 episodes among the 118 nontreated patients versus 4 episodes among 70 patients using mupirocin (0.14 ep/pt/yr vs 0.06 ep/pt/yr, respectively). Similarly there were 20 episodes of SA peritonitis among 118 patients during their first year of CAPD versus 4 episodes in 70 mupirocin-treated patients (0.16 ep/pt/yr vs 0.06 ep/pt/yr, respectively). No adverse effects were observed among the patients treated with mupirocin. Overall peritonitis rates decreased from 0.87 to 0.48 ep/pt/yr (p < 0.01) in Study 1 and from 0.56 to 0.41 ep/pt/yr (p = NS) in Study 2. We observed no differences in the incidence of exit-site infection and peritonitis rates among patients applying mupirocin ointment at the exit site daily, compared to three times per week., Conclusions: Mupirocin application at the exit site significantly lowers the incidence of SA exit-site infections and peritonitis due to SA infections. Since SA infections are accompanied by significant morbidity and occasional mortality, this treatment may improve long-term survival of patients on CAPD.

Objective: To review the role of Na,K-ATPase inhibitors in the pathogenesis of essential hypertension and hypertension associated with end-stage renal disease., Data Sources: MEDLINE search, 1966 to 1997., Results: There is a suggestive physiologic and epidemiologic relationship between Na,K-ATPase inhibition and hypertension. However, clearance data cannot support the hypothesis that differential metabolism of this family of compounds explains the improved hypertensive control seen in patients on peritoneal dialysis compared to those on hemodialysis., Conclusions: As a result of the complex methodologies involved, it is unclear whether Na,K-ATPase inhibitors play a significant role in the hypertension of end-stage renal disease in general and peritoneal dialysis in particular.

The sudden onset of hypertension mandates investigation for secondary causes. We report the case of a young man with a very rare systemic fungal disease that included massive unilateral perirenal adenopathy. Treatment was associated with the abrupt onset of severe hypertension. Imaging studies suggested progressive constriction of one kidney with treatment, presumably as a result of healing adenopathy. We suggest that this case is a new example of hypertension secondary to constrictive perinephritis (Page kidney).

Objective: This paper reviews protein flux and amino acid metabolism and the potential inaccuracies inherent in using urea kinetics as an estimate of these processes, particularly in the patient undergoing peritoneal dialysis. The problems of extrapolating these estimates back to the whole patient are examined, addressing assumptions about neutral nitrogen balance, and the difficult issue of normalizing urea-derived indices to body size., Conclusions: Urea kinetics can be a helpful tool for assessing nutritional indices, but there are many caveats and many pitfalls that must be kept in mind to avoid being lulled into a false sense of confidence by the comfort of numbers.

A 51-yr-old man presented with renal failure, proteinuria, hematuria, and hypertension. The serum contained two monoclonal protein spikes, an IgG4 lambda and free lambda light chains. Free gamma heavy chains were absent from serum. A bone marrow biopsy did not show evidence of a plasmalymphocytic dyscrasia. Renal biopsy showed a nodular glomerulopathy with linear deposits of gamma 4 heavy chains alone along glomerular, tubular, and vascular basement membranes and in mesangial regions. No light chains were detected in the kidney despite staining with antisera directed against both free and bound light chains and the F(ab')2 fragment of IgG. The term heavy-chain deposition disease is appropriate in view of the above features.

A 72-year-old woman with diabetic nephropathy receiving continuous ambulatory peritoneal dialysis for 1 year presented with recurrent episodes of sterile cloudy dialysate. Abdominal ultrasound and computed tomography demonstrated retroperitoneal masses. Cytology of the dialysis fluid revealed large atypical lymphocytes with light chain restriction, strongly suggestive of lymphoma. Fine-needle aspiration of the retroperitoneal masses showed cells with identical cytologic and immunocytochemical staining characteristics. This is the first report of de novo lymphoma diagnosed in a continuous ambulatory peritoneal dialysis patient by cytologic analysis of the dialysis effluent.

There is increasing evidence that erythropoietin (EPO) affects immune function in addition to its well-known effects on the erythrogenesis. However, many of the studies examining the immunomodulatory capacity of this hormone have been in vitro. We examined mRNA signal for three important cytokines, interleukin 1(IL-1), interleukin 6 (IL-6), and tumor necrosis factor alpha (TNF-alpha), in stable continuous ambulatory peritoneal dialysis (CAPD) patients at baseline, and again at 2, 4, and 6 months after treatment with EPO. Significant changes were noted in all three cytokine mRNA signals in the majority of patients treated with this hormone. We conclude that EPO has significant immunomodulatory effects in vivo as defined by changes in cytokine mRNA compared to control. The significance of these changes, and their relationship to well-being and altered immune function remain to be better defined.

For the diabetic patient on peritoneal dialysis, the intraperitoneal administration of insulin can lead to improvement in glycemic control while eliminating uncomfortable subcutaneous injections. Furthermore, the relatively higher portal vein concentrations of insulin compared to peripheral levels is reminiscent of the physiologic state in which the portal vein carries the insulin secreted by the pancreas. The pharmacokinetics of intraperitoneal insulin depends upon whether the insulin is administered along with the usual volume of dialysis fluid or is given undiluted. This variability has important implications for glycemic control in the patient receiving cycler peritoneal dialysis, particularly if the abdomen is dry for prolonged periods during the day. Recommendations are made based on the known pharmacokinetics of intraperitoneal insulin in both the dry and filled peritoneal cavity.

Four HIV-positive patients were shown to have IgA-associated nephritis on biopsy, including one with anaphylactoid purpura. Three were homosexuals, while the fourth acquired the infection from his mother. All had hematuria, a variable degree of proteinuria and renal disease with a benign course. Serologic studies showed elevated levels of IgA as well as IgA immune complexes and rheumatoid factor. IgA antibodies to multiple HIV antigens were detected by Western blot. Pathologic studies showed tubuloreticular inclusions in endothelial cells and nuclear bodies in interstitial cells in all cases. HIV antigens were not detected in kidney biopsies by monoclonal antibodies nor was HIV viral genome demonstrated by in situ hybridization. The possibility that this represents a unique type of IgA-associated HIV nephropathy is discussed.