The problem of pulmonary arterial hypertension in end-stage renal disease: can peritoneal dialysis be the solution.

BACKGROUND: Pulmonary arterial hypertension (PAH) in the setting of end-stage renal disease (ESRD) has important prognostic and therapeutic consequences. We estimated the prevalence of PAH among patients with ESRD treated with automated peritoneal dialysis (APD), investigated the effect of different variables and compared pulmonary artery pressure and cardiac function at the beginning and end of the study. METHODS: This is a 5-year study in which 31 ESRD patients on APD were recruited after fulfilling inclusion criteria. Blood samples were collected from all patients for the biochemical and hematological data at the beginning of the study and every month and at the study termination. Total body water (TBW) and extracellular water (ECW) were calculated using Watson's and Bird's calculation methods. All patients were followed-up at 3-month interval for cardiac evaluation. Logistic regression analysis was used to assess the relation between different variables and PAH. RESULTS: The mean age of the study population (n = 31) was 51.23 ± 15.24 years. PAH was found in 24.2% of the patients. Mean systolic pulmonary artery pressure (sPAP) and mean pulmonary artery pressure (mPAP) were significantly higher in the APD patients at study initiation than at the end of the study (40.75 + 10.61 vs 23.55 + 9.20 and 29.66 + 11.35 vs 18.24 + 6.75 mmHg respectively, p = 0.001). The median ejection fraction was significantly lower in patients with PAH at zero point than at study termination [31% (27-34) vs 50% (46-52), p = 0.002]. Hypervolemia decreased significantly at the end of study (p <  0.001) and correlated positively with the PAP (r = 0.371 and r = 0.369), p = 0.002). sPAP correlated with left ventricular mass index, hemoglobin level, and duration on APD. CONCLUSIONS: Long term APD (> 1 years) seemed to decrease pulmonary arterial pressure, right atrial pressure and improve left ventricular ejection fraction (LVEF). Risk factors for PAH in ESRD were hypervolemia, abnormal ECHO findings and low hemoglobin levels. Clinical and echocardiographic abnormalities and complications are not uncommon among ESRD patients with PAH. Identification of those patients on transthoracic echocardiography may warrant further attention to treatment with APD.

Is percutaneous gastrostomy tube insertion contraindicated in adult peritoneal dialysis patients? A single-centre experience of three successful cases: It is time to revisit.

Percutaneous endoscopic gastrostomy (PEG) tube placement in adults who are already established on peritoneal dialysis (PD) remains challenging due to the limited experience and data in this area which lacks clear guidance. Given the fact that peritoneal dialysis is one of the relative contraindications for PEG tube insertion, and PEG tube on its own is a risk for peritonitis, how to overcome these obstacles and utilize the advantage of PEG tube for feeding malnourished PD patients remains uncertain. Here we report our unique successful experience of treating three adult peritoneal dialysis patients in whom the PEG tube was inserted successfully with no complications. To the best of our knowledge, this is the first successful case series in the literature for treating adult prevalent PD patients by PEG tube placement.

Iatrogenic Hypothermia during Hemodialysis Can Induce Serious Cardiac Arrhythmias in Diabetic Patient.

Cardiovascular diseases are the main cause of morbidity and mortality in end-stage renal disease (ESRD) patients. Cardiac arrhythmias are prevalent in patients undergoing hemodialysis (HD), however, dialysis treatment per se can be considered as an arrhythmogenic stimulus. Uremic patients are characterized by a "pro-arrhythmic substrate" because of the high prevalence of ischemic heart disease, left ventricular hypertrophy, and autonomic neuropathy. The incidence of hypothermia in HD patient is unknown. The severity of hypothermia correlated to cardiac arrhythmias. Here, we report a 50-year-old Saudi lady known case of long-standing diabetes mellitus with diabetic retinopathy, nephropathy and neuropathy, ESRD on HD, coronary artery disease developed transient third-degree heart block secondary to iatrogenic hypothermia during HD session, which was completely resolved after adjusting temperature of dialysis machine. To the best of our knowledge, the association of third-degree atrioventricular block and hypothermia induced by HD session has not been previously reported.

Recurrent syndrome of inappropriate antidiuretic hormone secretion due to tolterodine in an elderly male patient.

Hyponatremia is defined as serum sodium of <135 mmol/L and equates with a low serum osmolality once translocational hyponatremia and pseudohyponatremia are ruled out. True hyponatremia develops when normal urine-diluting mechanisms are disturbed. In elderly patients, this complication is not uncommon, especially in nursing homes and assisted living facilities. Medications are often the most common cause of hyponatremia in these patients. Herewith, we reported a 65-year-old Saudi male, a known case of benign prostatic hypertrophy and hypertension, who developed recurrent hyponatremia secondary to tolterodine. To our knowledge, this is the fifth case reported in literature of such association.

Pregnancy in peritoneal dialysis and an infant with a ventricular septal defect.

Fertility is markedly reduced in dialysis patients. Estimates of the frequency of conception in dialysis patients range from 1.4% per year in Saudi Arabia to 0.5% in the United States. The reasons for the rarity of pregnancy in dialysis patients are not well understood. In addition, there is a marked increase in the risk of pre-eclampsia, hydramnios, hypertension crisis, early uterine contractions and pre-term delivery. Herein, we report a 38-year-old Saudi woman with chronic renal failure who completed the full term of pregnancy uneventfully on peritoneal dialysis. Using a biocompatible dialysate solution, adequate metabolic and blood pressure control were achieved during pregnancy. The delivered infant was small for gestational age and was born with a ventricular-septal defect. To the best of our knowledge, this is the first case report in the literature of ventricular-septal defect in an infant born to a mother on peritoneal dialysis.

An update on sickle cell nephropathy.

Sickle cell disease (SCD) is a major health problem in many countries. Sickle cell nephropathy (SCN) is now a well-characterized entity with specific manifestations, risk factors and prognosis. The presence of sickled erythrocytes in the renal medullary vessels is the hallmark of the disease with a variety of renal complications. Renal manifestations of SCD include renal ischemia, microinfarcts, renal papillary necrosis and renal tubular abnormalities with variable clinical presentations. Proximal tubule dysfunction generally impairs urinary concentration, while more distal tubule dysfunction may impair potassium excretion, leading to hyperkalemia. Glomerular disease with proteinuria may develop due to ischemia and results in a compensatory increase in the renal blood flow and glomerular filtration rate; such hyperfiltration, combined with glomerular hypertrophy, probably contributes to glomerulosclerosis. Acute and chronic kidney disease are the expected outcomes of the disease. Both dialysis and kidney transplantation are effective renal replacement therapies for end-stage renal disease due to SCN, with a higher advantage for transplantation. Whether bone marrow transplantation in the early stage of the disease can halt the progression of SCN is unknown and awaits clinical studies.

The influence of increased peritoneal membrane surface area on dialysis adequacy.

The adequacy of peritoneal dialysis is generally dependant on the choice of peritoneal fluid, the intraperitoneal fill volume and the contact time. Moreover, the peritoneal surface area acts as a major factor in the exchange dynamics of a peritoneal membrane. We designed a mechanism to increase the membrane surface contact area by using an abdominal belt in order to exert enough pressure on the fill volume, to effectively recruit more area in contact for exchange. We studied 12 patients on regular continuous ambulatory peritoneal dialysis (CAPD) at our center from January to October 2008. The age of patients ranged from 44 to 75 years, with a median of 55 years. All the patients were maintained on the same prescription four months before and during the study. Dialysis solutions were 1.36% Deaneal® , two liters, three exchanges and the last fill volume was two liters 7.5% Extraneal® . The belt was applied to all the patients most of the day and all night. We then observed its effect on dialysis adequacy, reflected by various parameters over a period of eight months. The average Kt/V before wearing the belt was 1.89 and improved after applying the belt to 2.3 (P <0.05). Our study suggests that increasing the abdominal pressure by wearing an abdominal belt rendered the filling volume of the PD dialysate to have a better contact with the peritoneal membrane and improved the dialysis adequacy. Studies with larger sample size are required to confirm the results.