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Background: Different studies in the past have shown that the risk of cancer development is increased in chronic dialysis patients. However, data concerning the cancer risk in Asian dialysis patients was scarce. More importantly, there was lack of information about the cancer-specific mortality in dialysis patients. Methods: A multicenter retrospective cohort study of 6,254 patients who started either chronic peritoneal dialysis or hemodialysis between 1994 and 2014 in 4 renal units in Hong Kong. Patterns of cancer incidence and mortality in our dialysis patients were compared with those of the general population using standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) respectively. Results: With 14,887 person-years of follow-up, 220 cancers were recorded. The SIR of all cancers was 1.44 (95% CI 1.26-1.65). A trend of an increased SIR was observed in young patients and within the first year of dialysis. Colorectum was the most common site of cancer (20%) while kidney cancer carried the highest risk (SIR 12.28, 95% CI 8.44-17.08). The SMR of all cancers was 0.91 (95% CI 0.72-1.13) and only kidney cancer had higher cancer mortality risk (SMR 4.92, 95% CI 1.80-10.70). SMR was highest in young patients and then decreased with age. Conclusions: The incidence of cancers in our chronic dialysis patients was elevated. Our findings of substantially increased risks in young patients, particularly in relation to kidney cancer, suggest that we can adopt a more individualized approach to cancer screening in chronic dialysis patients.

Background and Objectives Enterococci are part of the normal flora of the gastrointestinal tract. They can cause enteric peritonitis, which is a serious complication of peritoneal dialysis (PD). However, the clinical course and outcome of PD-related Enterococcus peritonitis remains unclear. Methods We reviewed all Enterococcus peritonitis episodes occurring in our dialysis unit from 1995 to 2009. Results During the study period, 1421 episodes of peritonitis were recorded. Of 29 episodes (2.0%) that were attributable to single-organism Enterococcus, 12 episodes were caused by E. faecalis; 9, by E. faecium; and the remaining 8, by other Enterococcus species. The overall rate of ampicillin resistance was 41.4%. Recent use of antibiotics was associated with the development of ampicillin-resistant Enterococcus (ARE) peritonitis (hazard ratio: 12.53; p = 0.04). The primary response rate of Enterococcus peritonitis was significantly higher than that of Escherichia coli peritonitis (89.7% vs. 69.9%, p = 0.038), but the primary response rate was not significantly lower for ARE peritonitis than for ampicillin-susceptible Enterococcus (ASE) peritonitis (83.3% vs. 94.1%, p = 0.553). However, significantly more patients with ARE had received vancomycin (83.3% vs. 23.5%, p = 0.003), with a longer mean duration of vancomycin treatment (11.8 ± 6.9 days vs. 3.7 ± 6.8 days, p = 0.005). Conclusions Recent use of antibiotics was a risk factor for the development of ARE peritonitis. Outcomes in ASE and ARE peritonitis were similar, but vancomycin was required during treatment for ARE peritonitis, in turn possibly predisposing the patients to infections caused by vancomycin-resistant organisms.

Background and Objective The downward directed exit of the swan neck catheter may decrease the risk of exit-site infection (ESI). The percentage of migrations of the swan neck catheter seems to be less than the conventional Tenckhoff catheter and the swan neck catheter is more expensive and cannot be manipulated by guidewire technique if tip migration occurs. In this study, the conventional Tenckhoff catheter was used. The straight tunnel was converted to an arcuate one using the triple incision method, resulting in a downward directed exit. The arcuate tunnel was created by passing the catheter through an additional incision located between the paramedian incision and the exit site. We compared the infective and mechanical complications of the Tenckhoff catheter with a downward exit, implanted using the triple incision method, with the swan neck catheter. Patients and Methods 101 new peritoneal dialysis patients were prospectively randomized to receive either the Tenckhoff catheter with a downward exit, implanted using the triple incision method, or the swan neck catheter. Each patient was followed up for 24 months. 50 patients were in the triple incision method group (TIMG) and 51 were in the swan neck catheter group (SNCG). Results Over a mean period of 18.9 ± 8.0 months of follow-up, ESI occurred in 35 patients (70%) in TIMG and 37 patients (72.5%) in SNCG ( p = 0.83). The ESI rates were 0.71 and 1.0 episodes/catheter-year in TIMG and SNCG respectively ( p = 0.21). The peritonitis rates were similar in the 2 groups (0.64 episodes/year in TIMG and 0.68 episodes/year in SNCG, p = 0.47). More patients in TIMG had tip migration [15 patients (30%) in TIMG vs 10 patients (19.6%) in SNCG] but the difference was not statistically significant. Repositioning of the catheter by guidewire manipulation was successful in patients in TIMG but not in SNCG. Overall catheter survival at 12 and 24 months was 95% and 83% in TIMG and 93% and 79% in SNCG respectively ( p = 0.72). Conclusion By using the conventional Tenckhoff catheter with a downward exit created using the triple incision method, high catheter survival rates with infective and mechanical complication rates similar to those of the swan neck catheter can be achieved. The triple incision method has the additional advantages of lower cost and the catheter can be manipulated by guidewire technique if tip migration occurs.

Background The impact of a low-glucose peritoneal dialysis (PD) regimen on biomarkers of peritoneal inflammation, fibrosis and membrane integrity remains to be investigated. Methods In a randomized, prospective study, 80 incident PD patients received either a low-glucose regimen comprising Physioneal (P), Extraneal (E) and Nutrineal (N) (Baxter Healthcare Corporation, Deerfield, IL, USA) (PEN group), or Dianeal (control group) for 12 months, after which both groups continued with Dianeal dialysis for 6 months. Serum and dialysate levels of vascular endothelial growth factor (VEGF), decorin, hepatocyte growth factor (HGF), interleukin-6 (IL-6), macrophage migration inhibitory factor (MIF), hyaluronan (HA), adiponectin, solubleintracellular adhesion molecule (s-ICAM), vascular cell adhesion molecule-1 (VCAM-1) and P-selectin, and dialysate cancer antigen 125 (CA125), were measured after 12 and 18 months. This paper focuses on results after 12 months, when patients in the PEN group changed to glucose-based PD fluid (PDF). Results At the end of 12 months, effluent dialysate levels of CA125, decorin, HGF, IL-6, adiponectin and adhesion molecules were significantly higher in the PEN group compared to controls, but all decreased after patients switched to glucose-based PDF. Macrophage migration inhibitory factor level was lower in the PEN group but increased after changing to glucose-based PDF and was similar to controls at 18 months. Serum adiponectin level was higher in the PEN group at 12 months, but was similar in the 2 groups at 18 months. Body weight, residual renal function, ultrafiltration volume and total Kt/V did not differ between both groups. Dialysate-to-plasma creatinine ratio at 4 h was higher in the PEN group at 12 months and remained so after switching to glucose-based PDF. Conclusion Changes in the biomarkers suggest that the PEN PD regimen may be associated with better preservation of peritoneal membrane integrity and reduced systemic vascular endothelial injury.

Objective Superior patient survival on continuous ambulatory peritoneal dialysis (CAPD) with 3 x 2-L exchanges has been reported from Hong Kong. This study examined the relationship between indices of dialysis adequacy and nutrition and patient survival on CAPD in Hong Kong. Design A cross-sectional study on prevalent CAPD patients. Patients were assessed for indices of dialysis adequacy and nutritional status with a composite nutritional index (CNI). Patients were then followed for 24 months. Survival data were analyzed according to adequacy indices and nutritional status. Setting All prevalent CAPD patients in nine dialysis centers in Hong Kong as of 1 April 1996. Main Outcome Measure Mortality. Results 937 patients were assessed: 68.2% were using 3 x 2-L exchanges per day; mean age was 54.6 ± 13 years. Mean total Kt/V was 1.83 ± 0.42 and total creatinine clearance was 55.6 ± 19.5 L/week/1.73 m2. 19% of patients were moderately to severely malnourished according to the CNI. There was no significant correlation between indices of adequacy and serum albumin or CNI. The 1- and 2-year patient survival from the time of assessment was 90.9% and 79.8%. There was a trend toward better survival in patients with Kt/V greater than 2.0, but it was not statistically significant. Peritoneal Kt/V did not impact survival in anuric patients. Malnourished patients had poorer survival than patients who were better nourished ( p = 0.0259). After adjusting for age and diabetes, CNI was predictive of mortality but Kt/V and creatinine clearance were not. Conclusions This study demonstrates the importance of nutritional status over adequacy indices in predicting patient survival. There was a lack of correlation between nutritional status and conventional indices of dialysis adequacy.

ObjectiveWe compared outcomes for catheters with different configurations: conventional straight, swan-neck straight tip, and swan-neck curled tip.DesignThe study was conducted as a prospective randomized controlled trial in the continuous ambulatory peritoneal dialysis (CAPD) unit of a university center.Patients and MethodsWe randomized 93 new regular CAPD patients without prior peritoneal dialysis (PD) catheter insertion to receive a conventional straight, double-cuffed catheter (CS), a swan-neck straight catheter (SNC), or a swan-neck curled tip catheter (SNC) in 2:1:1 ratio.ResultsThe exit-site infection (ESI) rate was slightly lower with swan-neck catheters as compared with straight catheters, but the difference was not statistically significant. The peritonitis rate and overall catheter survival were similar. In Staphylococcus aureus nasal non carriers as compared with carriers, ESI-free catheter survival was significantly better with swan-neck catheters ( p = 0.0302 and p = 0.82 respectively). As compared with SC catheters, SNC catheters had a significantly higher migration rate ( p = 0.022).ConclusionsSwan-neck catheters were associated with a slightly better ESI rate, but SNC catheters are not routinely recommended because of a high migration rate. The SNS catheter is therefore recommended as the first-line catheter of choice, particularly in populations with a low rate of S. aureus nasal carriage.

Effect of Kt/V on survival and clinical outcome in CAPD patients in a randomized prospective study.BackgroundThere has been a lack of randomized control study on the effect of Kt/V on patient outcome. This interventional study was designed to examine the effect of Kt/V on continuous ambulatory peritoneal dialysis (CAPD) patients' clinical outcome and nutritional status in a randomized prospective manner.MethodA total of 320 new CAPD patients with baseline renal Kt/V 2.0. Kt/V and nutritional status were assessed every 6months and dialysis prescription adjusted accordingly. Nutritional assessment included serum albumin and composite nutritional index (CNI). Patients were allowed to withdraw at the discretion of their physicians or themselves.ResultsTotal Kt/V were significantly different between groups (P = 0.000) and the difference was contributed by peritoneal Kt/V only. The overall 2-year patient survival was 84.9%. There was no statistical difference in patient survival among the three groups (2-year survival in group A, 87.3%; group B, 86.1%; and group C, 81.5%). However, there were more patients withdrawn by physicians in group A (group A, 16; group B, 7; and group C, 6; P = 0.023). Total Kt/V or Kt did not significantly affect survival after adjustment to age and diabetes. There was no difference in serum albumin, CNI scores, and hospitalization rate, but there were more patients in group A requiring erythropoietin (EPO) treatment after 1year.ConclusionPatients with total Kt/V maintained below 1.7 had significantly more clinical problems and severe anemia but there was no difference in outcome demonstrated for patients with Kt/V maintained above 2.0 and between 1.7 and 2.0. We recommended that the minimal target of total Kt/V should be above 1.7.