The impact of various cycling regimens on phosphorus removal in chronic peritoneal dialysis patients.

BACKGROUND: The National Kidney Foundation Dialysis Outcome Quality Initiative clinical practice guidelines have suggested that serum phosphate levels be maintained at < or =5.5 mg/dL in patients maintained on dialysis. Over 45% of anuric patients maintained on CAPD have serum phosphate levels >5.5 mg/dL. The present study was designed to address the question whether phosphate removal could be enhanced by increasing the dialysate volume during cycler peritoneal dialysis therapy. METHODS: Medically stable patients maintained on chronic peritoneal dialysis therapy, who were high or high-average transporters and had serum phosphate levels > or =5.5 mg/dL, were invited to participate in the study. The protocol involved measuring phosphate and creatinine clearances at weekly intervals on three different cycler prescriptions consisting of 7 and 12 full cycles or 24 cycles with 50% tidal PD (TPD) over 9 hours. Ten patients agreed to participate. Those patients (n=7) with a BMI > 22 had 2 liter (L) fill volumes and 14 L of total dialysate (7 cycles of 2 L) or 24 L total dialysate (12 cycles of 2 L or 50% TPD with 24 cycles).The patients (n=3) with a BMI < 20 had 1.2 L fill volumes and 8.4 L total dialysate (7 cycles) or 14.4 L total dialysate (12 cycles of 1.2 L or 50% TPD with 24 cycles). RESULTS: The mean age (+/- SD) of the study patients was 50.8 (+/- 9.3) years. There were 6 females, 6 Caucasians and 4 African-Americans. The mean weight of the patients was 71.5 (+/- 24.2) kg and mean height 1.65 (+ 7.6) meters. The mean BMI was 18.3 (+/- 1.27) in the < 20 BMI group and 30.3 (+/- 6.6) in the > 22 BMI group. The mean phosphate clearance (L/night/1.73m 2 ) increased from 3.96 (+/- 1.16) with 7 cycles to 4.71 (+ 1.81) with 12 cycles and 4.51 (+/- 1.61) with 50% TPD. Creatinine clearance (L/night/1.73m 2 ) was 4.74 (+/- 1.74) with 7 cycles, 6.06 (+/- 2.04) with 12 cycles and 5.61 (+/- 2.01) with TPD. CONCLUSION: The present study indicates that there is a significant, 19% (P < 0.005) rise in phosphate clearance by increasing dialysate volume 71% from 7 cycles to 14 cycles compared to a 27% increase in creatinine clearance. With tidal PD, phosphate clearance increased by 12% (p=NS) and creatinine clearance increased 18 % (p, 0.02). This increase in phosphate clearance translates into <50 mg net phosphate removal in 9 hours, assuming a serum phosphate of 6 mg/%. Thus, increasing dialysis cycles and volume results in only a minimal increase in net phosphate removal.

Tidal peritoneal dialysis: comparison of different tidal regimens and automated peritoneal dialysis.

BACKGROUND: The National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI) clinical practice guidelines have suggested minimal weekly Kt/V urea and creatinine clearance goals for peritoneal dialysis patients maintained on continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). Achieving these goals may present problems, particularly in larger patients whose residual renal function declines. Thus, modifications of the dialysis regimen, such as tidal peritoneal dialysis (TPD), have been developed. However, the ability of TPD to improve the efficiency of the dialysis procedure remains uncertain. METHODS: Stable, cycling peritoneal dialysis patients were placed into two groups to study the effectiveness of different TPD prescriptions on peritoneal clearances of urea and creatinine. The volume of dialysis solution used and the duration of therapy were fixed in the two groups. Comparisons were made to conventional APD using multiple hourly cycles in which spent dialysis solution was completely drained with each cycle. Group I patients received a total of 15 L of PD solution over 9.5 hours in the dialysis unit. These patients received 10, 25, and 50% TPD and APD on four separate days. Group II patients received 24 L of PD solution over 9.5 hours. These patients received 25 and 50% APD on separate days in the dialysis unit. Peritoneal dialysis clearances for urea (pKt/V) and creatinine (pCCr) levels were calculated for both groups. The results were then analyzed to determine whether there was any significant difference among the various prescriptions. RESULTS: The data in the group I patients indicated a mean daily pKt/V of 0.22 +/- 0.03 with 10% TPD, 0.23 +/- 0.02 with 25% TPD, 0.25 +/- 0.02 with 50% TPD, and 0.26 +/- 0.02 with APD. Paired t-test analysis for pKt/V demonstrated that 10 and 25% TPD resulted in significantly lower values than 50% TPD and APD (P < 0.05). Mean daily pCCr L/24 h/1.73 m2 was 6.03 +/- 0.72 for 10% TPD, 6.34 +/- 0.83 for 25% TPD, 6.65 +/- 0.51 for 50% TPD, and 7.01 +/- 0.96 for APD; these differences were not significantly different. The data in the group II patients demonstrated a mean daily pKt/V of 0.28 +/- 0.03 with 25% TPD, 0.29 +/- 0.05 with 50% TPD, and 0.30 +/- 0.05 for APD. The mean daily pCCr was 6.69 +/- 0.47 for 25% TPD, 8.09 +/- 1.30 for 50% TPD, and 7.63 +/- 1.13 for APD. There were no statistical differences for pKt/V and pCCr within the 24 L group. CONCLUSION: When the duration of therapy and volume of dialysate volume are kept constant, TPD does not result in an improvement in clearances compared with conventional APD, at least with dialysate volumes up to 24 L.

Incidence of peritonitis in chronic peritoneal dialysis patients infused with intravenous iron dextran.

BACKGROUND: The Dialysis Outcomes Quality Initiative (DOQI) guidelines, published in 1997, emphasize the need for careful monitoring of iron stores and for provision of adequate iron replacement therapy to achieve target goals of hemoglobin concentration in end-stage renal disease (ESRD) patients, especially those treated with recombinant erythropoietin (rHuEPO). Intravenous iron dextran (IVID) therapy, which has long been used in hemodialysis patients, is increasingly being used in chronic peritoneal dialysis (CPD) patients. In 1997, we began using this form of iron therapy for our CPD patients. However, because considerable data exists to show a relationship between iron metabolism and acute infections, we questioned whether IVID infusion placed our patients at greater risk for peritonitis, the leading cause of death and patient drop-out from CPD therapy. OBJECTIVE: To evaluate the relationship between iron and infection, we studied episodes of peritonitis in CPD patients who were infused with IVID. DESIGN: In a retrospective study of adult CPD patients who received IVID during 1998, we investigated the occurrence of peritonitis episodes and the spectrum of causative organisms. Patients with a hemoglobin level of < 12.5 g/dL who also had a ferritin level < 100 ng/mL or a transferrin saturation level < 20% (or both) and who did not respond to oral iron therapy, were administered between 0.5 g and 1.0 g of IVID in an outpatient hospital setting. We calculated the expected and observed number of peritonitis episodes in these patients within 30, 60, and 90 days after infusion of IVID. RESULTS: During the study period, 56 patients received 77 doses of IVID, with 14 patients requiring 2 or more infusions. Of the 77 doses, 71 were given as a 1-g bolus. The IVID was well tolerated by all patients. Within 90 days of IVID administration, 14 patients developed peritonitis: 6 episodes occurred within 30 days, 7 episodes occurred between 31 and 60 days, and 1 episode occurred between 61 and 90 days after the IVID dosing. The peritonitis rate for patients not receiving IVID was 1 episode per 13.7 patient-months. Taking this rate as the "expected" rate, the expected number of episodes of peritonitis for the study population was 5.6 episodes within 30 days, 11.2 episodes within 60 days, and 16.8 episodes within 90 days following IVID administration. The difference between the expected and observed rates of peritonitis in patients who were dosed with IVID was not statistically different. The spectrum of organisms seen in the peritonitis episodes in the study population was not significantly different from that seen in the peritonitis episodes in our CPD unit population. CONCLUSIONS: There is evidence that IVID infusion therapy can improve anemia and reduce rHuEPO requirements in CPD patients, usually without adverse reaction and without exposing patients to an increased risk of peritonitis. More research is needed in the area of potential increased risk of infection in ESRD patients who are (1) infused with large doses of IVID, and (2) iron-overloaded.

Value of scintigraphy in chronic peritoneal dialysis patients.

BACKGROUND: A variety of factors can adversely impact chronic peritoneal dialysis (CPD) as an effective renal replacement therapy for patients with end-stage renal disease. These factors include peritonitis, poor clearances, loss of ultrafiltration, and a variety of anatomic problems, such as hernias, peritoneal fluid leaks, loculations, and catheter-related problems caused by omental blockage. This study reviews our experience with peritoneal scintigraphy for the evaluation of some of these difficulties. METHODS: From 1991 to 1996, 50 peritoneal scintigraphy scans were obtained in 48 CPD patients. Indications for scintigraphy were evaluated, and the patients were placed into four groups: group I, abdominal wall swelling; group II, inguinal or genital swelling; group III, pleural fluid; and group IV, poor drainage and/or poor ultrafiltration. A peritoneal scintigraphy protocol was established and the radiotracer isotope that was used was 2.0 mCi of 99mtechnetium sulfur colloid placed in two liters of 2.5% dextrose peritoneal dialysis solution. RESULTS: Ten scans were obtained to study abdominal wall swelling, with seven scans demonstrating leaks; six of these episodes improved with low-volume exchanges. Twenty scans were obtained to evaluate inguinal or genital swelling, and 10 of these had scintigraphic evidence for an inguinal hernia leak (9 of these were surgically corrected). One of four scans obtained to evaluate a pleural fluid collection demonstrated a peritoneal-pleural leak that corrected with a temporary discontinuation of CPD. Sixteen scans were obtained to assess poor drainage and/or ultrafiltration. Five of these scans demonstrated peritoneal location, and all of these patients required transfer to hemodialysis. The other 11 scans were normal; four patients underwent omentectomies, allowing three patients to continue with CPD. CONCLUSION: Peritoneal scintigraphy is useful in the evaluation and assessment of CPD patients who develop anatomical problems (such as anterior abdominal, pleural-peritoneal, inguinal, and genital leaks) and problems with ultrafiltration and/or drainage.

Tidal peritoneal dialysis to achieve comfort in chronic peritoneal dialysis patients.

Patients with end-stage renal disease on chronic peritoneal dialysis (CPD) can usually tolerate continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) without abdominal discomfort or pain. In some patients, pain or discomfort occurs with complete drain of the peritoneal dialysis solution or upon initiation of dialysis filling when the peritoneal cavity is empty. We report on the use of tidal peritoneal dialysis (TPD) as a modality to alleviate this pain. Of 136 patients in our CPD unit, 18 (13%) were complaining of pain with complete drain or upon instillation of PD fluid. All were placed on TPD after other causes for abdominal pain were excluded. Six patients were placed on 25% TPD, and 12 patients on 50% TPD. The mean Kt/V of the patients on TPD was 2.46 +/- 0.68. With TPD, all patients had complete relief of abdominal discomfort. Patients who develop abdominal pain with complete drain or fill when the abdominal cavity is empty would benefit from TPD and be able to continue with CPD.

Adequacy of CPD: comparing Kt/V and creatinine clearance.

Presently, adequate dialysis in continuous peritoneal dialysis (CPD) patients is assessed by monitoring urea kinetics (Kt/V) or by measuring the total creatinine clearance (CC). Target Dialysis Outcome Quality Initiative (DOQI) goals are a weekly Kt/V of at least 2.0, and a CC of at least 60 L/wk per 1.73 m2. One hundred and four CPD patients in the New Haven continuous ambulatory peritoneal dialysis (CAPD) unit had their most recent Kt/V and CC reviewed. Of these patients, 58.7% attained the DOQI goals for Kt/V and CC, 14.4% had an acceptable Kt/V but low CC, 11.5% had an acceptable CC but low Kt/V, and 15.4% had both low Kt/V and low CC. A CC > 60 L/week per 1.73 m2 was associated with a residual renal function of > 25 L/wk per 1.73 m2. For a Kt/V of > 2.0, good residual renal function was helpful but not essential. A question left unanswered is whether patients with a low Kt/V and an adequate CC or low CC and acceptable Kt/V need more dialysis.

Hyperparathyroidism: a seven-year follow-up.

Hyperparathyroidism (HPT) is a common finding in patients with end-stage renal disease (ESRD). Most chronic peritoneal dialysis (CPD) patients with HTP can be successfully managed with phosphate binders, calcium supplements, and calcitriol therapy. Noncompliance with diet, prescribed binder, or calcitriol therapy may also lead to HPT. We reviewed New Haven CAPD unit patients who failed medical therapy and required parathyroidectomy (PTX) for control of severe HPT [sustained immunoreactive parathyroid hormone (iPTH) level > 600 pg/mL]. From 1990 to 1997, 18 out of 620 patients (3.0%) required PTX. Time on dialysis prior to PTX was 44.8 +/- 17.5 (mean +/- SD) months with a range of 13 to 71 months. The mean age was 43.6 +/- 11.8 years with a range of 30 to 66 years. There were 10 females and 8 males. Of the 18 patients, 14 had total parathyroidectomy with arm implants, and 4 had subtotal PTX. Seven of 18 patients had iPTH levels of < 100 pg/mL at 1 year post-PTX (5 patients with arm implants, 2 with subtotal PTX). Three patients required partial arm implant PTX to correct recurrent HPT. Pulse oral calcitriol (POC) was prescribed in 10 patients post PTX to maintain iPTH at target levels. Parathyroidectomy was necessary to correct HPT in 18 of 620 CPD patients from 1990 to 1997. The majority of these patients had excellent results after their PTX. Intact PTH levels of < 100 pg/mL for 1 year or more were noted in 5 of 14 patients with arm implants, and 2 of 4 patients with subtotal PTX. The significance of a persistent iPTH of < 100 pg/mL has yet to be determined in CPD patients.

Psychosocial factors and clinical outcome on CAPD.

Patient dropout from chronic peritoneal dialysis (CPD) and transfer to hemodialysis remains a major problem with patients on CPD. Peritonitis, exit-site infections, and medical complications requiring hospitalization often adversely affect the outcome of CPD. The role of psychosocial factors in determining patient outcome and influencing the rates of these complications is not clear. Our group has employed a variety of instruments, including the Patient Related Anxiety Scale (PRAS), Beck's Depression Inventory (BDI), Kupfer-Detre System II somatic symptom scale (KDS-II), and a patient self-assessed quality of life (PAQOL) questionnaire to assess quality of life and to objectively evaluate the psychosocial status of the patient treated with CPD. The present study extends previous observations by relating the results of these psychosocial instruments to the incidence of various complications in 103 patients maintained on CPD. Patients were divided into low-scoring (lowest symptoms of depression, anxiety, somatic symptoms, and best quality of life evaluation), intermediate, and high-scoring (highest symptoms of depression, anxiety, somatic symptoms, and worst quality of life) categories. The peritonitis rates, exit-site infection rates, and days of hospitalization of the three categories were then compared. The results demonstrate significantly higher complication rates in the high-scoring when compared to the low-scoring patients. Thus screening patients maintained on CPD with objective measures of psychosocial functioning may enable caregivers to more accurately predict which patients are at greater risk for developing medical complications.

Quality of life assessment in chronic peritoneal dialysis patients.

Previous studies by our group have attempted to examine quality of life (QoL) issues in a cohort of end-stage renal disease (ESRD) patients maintained on chronic peritoneal dialysis (CPD) by assessing a variety of psychological tests and by asking patients to rate their own QoL. The present study was undertaken to extend previous observations by asking patients to spontaneously select those domains of life experience that they think are most important in determining their quality of life. Sixty-eight medically stable CPD patients were asked to spontaneously select those three to five domains felt to be most important to them in defining their QoL. The 307 responses were then grouped into 22 broad categories by three investigators. The most frequently selected domains focused on interpersonal relationships. Domains that enhance the quality of one's day and add meaning to one's life were selected with a midrange frequency. Some domains that might intuitively seem to be important for a patient's QoL were selected with a surprisingly low frequency. These findings suggest that to understand what CPD patients value in assessing their QoL can best be determined by asking them directly and not by using predetermined variables.

Sexual experience of the chronic peritoneal dialysis patient.

The actual and desired frequency of intercourse was studied in 68 randomly selected chronic peritoneal dialysis (CPD) patients. The results were correlated with standard measures of depression (Beck Depression inventory), anxiety (Patient Related Anxiety Scale), physical symptoms (Kupfer-Detre System 2), adequacy of dialysis (KT/Vurea) and nutrition (serum albumin level). In addition, patients assessed their quality of life (PAQOL) using an 1 to 10 analog scale. The mean +/- SD age of all patients studied was 54 +/- 11 yr, the mean dialysis duration was 24 +/- 24 months; 46% of the patients were female, and 34% were diabetic. Sixty-three percent of the patients reported never having intercourse (Group 1), 19% reported having intercourse < or = two times per month (Group II), and 18% reported having intercourse > two times per month (Group III). Dialysis duration, serum albumin level, KT/Vurea, and age were not significantly different among the three groups. Nearly 50% of patients in Group I desired to have intercourse, and 54% of the patients in Group II desired to have intercourse more frequently, Group I patients had significantly higher depression and anxiety scores, more physical symptoms, a poorer overall PAQOL, and less satisfaction with their sexual activity than Group III patients. These results suggest that there is a high prevalence of sexual difficulties in CPD patients. Patients not having intercourse have a poorer quality of life and higher degree of depression and anxiety than patients having intercourse more than two times per month.

Quality of life in peritoneal dialysis patients.

In 49 patients receiving continuous ambulatory peritoneal dialysis, we assessed the relative influences of adequacy of dialysis (assessed by kinetic transfer/volume urea) and psychological symptoms (depression and anxiety) upon the patients' evaluation of their overall quality of life (QoL). Subjects completed self-rating forms for anxiety, depressive, and somatic symptoms, for discrete areas relevant to QoL, and for overall QoL; clinicians also rated QoL. Depressive symptoms proved a much stronger correlate of overall QoL than did the biochemical measure of dialysis adequacy, and they remained influential even after adjustment for anxiety, kinetic transfer/volume, and somatic symptoms. In contrast, the effects of kinetic transfer/volume, anxiety symptoms, and somatic symptoms dropped sharply when adjusted for the other variables. Because psychological (especially depressive) symptoms may be stronger determinants of patients' overall QoL than is adequacy of dialysis, assessing QoL and psychological status should be part of the care of end-stage renal disease patients.

Psychosocial factors and incidence of peritonitis.

It has been suggested that psychosocial (PS) factors may influence morbidity and mortality in chronically ill patients. However, investigators have not examined how PS factors affect specific medical problems in chronic peritoneal dialysis (CPD) patients. Sixty-eight patients maintained on CPD therapy were studied. PS testing included a self-rating form of patient-assessed quality of life (PaQOL), depression [Beck's Depression Inventory (BDI)], anxiety [Patient Rated Anxiety Scale (PRAS)], and assessment of physical symptoms (KDS-II). Peritonitis rates six months prior to PS assessment and six months after assessment were tabulated. The data show that during the study period patients with more than one episode of peritonitis compared to those with no episodes of peritonitis had: (1) significantly higher anxiety and physical symptom scores; (2) significantly lower PaQOL; and (3) higher depression scores, which did not reach statistical significance (p < 0.06). Whether higher peritonitis rates result in worse PS symptoms, or whether poor PS symptoms cause higher peritonitis rates needs to be determined with further investigations.

Comparison of continuous ambulatory peritoneal dialysis-related infections with different "Y-tubing" exchange systems.

Despite several modifications of the continuous ambulatory peritoneal dialysis (CAPD) technique over the last decade, peritonitis remains a major source of morbidity and is the leading cause of dropout for patients maintained on CAPD therapy. Recently, Baxter Healthcare introduced the Ultra Twin bag system, which uses drainage and infusion bags both secured to Y connecting tubing. Previous nonrandomized studies comparing the Ultra Twin bag system with other systems have indicated an improvement in the peritonitis rate with the Ultra Twin bag system. In this study, 82 patients were randomized to use the Ultra Twin bag system or the Ultra Y-set system, which uses only the drainage bag already attached to the Y connecting tubing. Peritonitis rates were significantly lower with the Ultra Twin bag system, one episode per 33.9 patient months, compared with the Ultra Y-set system, one episode per 11.7 patient months (P < 0.05). Furthermore, the 1-yr infection-free survival rates with the Ultra Twin bag system and the Ultra Y-set system were 71 and 40%, respectively. Exit-site infections were lower with the Ultra Twin bag system, one episode per 12.5 patient months, compared with the Ultra Y-set system, one episode per 28.3 patient months, although this difference was not statistically significant (P = 0.084). The effect of the reduction in the infection rate on patient dropout with the Ultra Twin bag system remains to be addressed.

Outcome of polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients.

Polymicrobial peritonitis is a relatively uncommon, but potentially serious complication that develops in continuous ambulatory peritoneal dialysis (CAPD) patients. Its cause and optimal management remain controversial. The authors reviewed the frequency and natural history of polymicrobial peritonitis in 432 CAPD patients. Of 1,405 episodes of peritonitis, 80 were polymicrobial (6%). Patients with polymicrobial peritonitis were similar to all CAPD patients in age, gender, race, and underlying renal disease. Diabetes mellitus, human immunodeficiency virus (HIV) status, and clinically apparent gastrointestinal disease did not predisposes patients to polymicrobial peritonitis. Thirty days after the polymicrobial peritonitis, 64 patients remained on CAPD (80%), and at 180 days 48 patients continued CAPD. Prior exit-site infections were present in 12 patients (14%) with polymicrobial peritonitis. Only 22% of patients required catheter removal to treat the infection. We conclude that polymicrobial peritonitis accounts for 6% of the total episodes of peritonitis; diabetes, HIV infection, and underlying gastrointestinal disease are not more prevalent in patients with multiorganism infections. Most patients continue CAPD therapy at 30 and 180 days after the episode of polymicrobial peritonitis.

Abdominal abscesses complicating peritonitis in continuous ambulatory peritoneal dialysis patients.

Ten patients with end-stage renal disease maintained on continuous ambulatory peritoneal dialysis therapy developed abdominal abscesses between 1982 and 1992. During this period, 537 patients cared for in our continuous ambulatory peritoneal dialysis unit developed 1,345 episodes of peritonitis. All abdominal abscesses were attributed to concomitant or antecedent peritonitis, suggesting that abscesses developed in 0.7% of peritonitis episodes. Abdominal pain, tenderness, fever, and nausea and vomiting were the most common presenting symptoms and signs. Radiographic findings that were helpful in establishing the diagnosis included abnormalities on computed tomography (CT) scanning, ultrasound, and Indium scanning. Seven patients developed intraperitoneal abscesses, two developed abdominal wall abscesses, and one developed both abdominal wall and intraperitoneal abscesses. Drainage of the abscesses was performed in all cases either surgically or percutaneously. Two patients died. The remaining eight patients have been maintained on hemodialysis therapy. The present data suggest that abdominal abscesses are uncommon complications of continuous ambulatory peritoneal dialysis-associated peritonitis. Prompt diagnosis by clinical criteria and radiographic techniques is important to permit appropriate drainage of the abscess cavity.

Pulse oral calcitriol to treat hyperparathyroidism in 43 CAPD patients.

To further study the effect of pulse oral calcitriol on the level of intact parathyroid hormone (iPTH), we have studied the response of 43 patients treated with 5.0 mcg calcitriol bi-weekly for one year. Mean iPTH decreased from 603 pg/mL +/- 262 (+/- SD) to 222 pg/mL +/- 185 (p < 0.001). Thirty-six patients responded showing a decrease in iPTH from baseline; 7 patients showed no decrease in iPTH. Transient hypercalcemia (calcium > 10.5 mg/dL) was noted in 6 patients of the responder group which corrected with temporary discontinuation of pulse therapy. Pulse oral calcitriol is an effective therapy to decrease elevated iPTH levels in continuous ambulatory peritoneal dialysis (CAPD) patients with hyperparathyroidism.

Selected outcome criteria and adequacy of dialysis in diabetic and elderly patients on CAPD therapy.

There has been a gradual increase in the number of diabetic and elderly patients maintained on continuous ambulatory peritoneal dialysis (CAPD) replacement therapy. Eighty randomly selected patients were studied over two years. Weekly normalized urea clearance (KT/Vurea), weekly creatinine clearance/1.73 m2 body surface area (BSA) (Ccr), and protein catabolic rate (PCR) were measured. Selected clinical outcome criteria were assessed. Weekly KT/Vurea was correlated with weekly Ccr (r = 0.538, p < 0.001), and weekly KT/Vurea was correlated with PCR (r = 0.393, p < 0.001). Patients were then stratified according to presence or absence of diabetes mellitus and age > 60 or < or = 60 years. Diabetic and nondiabetic patients had similar weekly KT/Vurea, weekly Ccr, PCR, serum albumin levels, weekly erythropoietin (EPO) requirements, peritonitis rates, and CAPD-related hospitalization rates. The total hospitalization rates, however, were higher in diabetic patients. Elderly and younger patients had similar weekly KT/Vurea, weekly Ccr, PCR, serum albumin levels, and weekly EPO requirements. Elderly patients, however, had higher peritonitis rates and higher total and CAPD-related hospitalization rates.

Hyperparathyroidism in CAPD patients: therapy with pulse oral calcitriol.

Hyperparathyroidism remains a cause of significant morbidity in dialysis patients. We studied pulse oral calcitriol, 5.0 micrograms biweekly to control hyperparathyroidism in 12 continuous ambulatory peritoneal dialysis (CAPD) patients. Parathyroid hormone (PTH) levels fell, while calcium and phosphorus levels remained in good control. Pulse oral calcitriol is an effective therapy for hyperparathyroidism in CAPD patients.

Weekly KT/V urea and selected outcome criteria in 56 randomly selected CAPD patients.

The optimal way to objectively measure the adequacy of continuous ambulatory peritoneal dialysis (CAPD) therapy remains controversial. It has been suggested that one-third or more of all CAPD patients are presently receiving "inadequate dialysis" when dialysis prescriptions are not carefully calculated. To better define the therapy being delivered in a large, freestanding CAPD center, weekly KT/V urea and creatinine clearance per 1.73 m2 body surface area were measured in 56 of 180 patients randomly selected from our unit in whom dialysis prescriptions were arbitrarily determined by nurses and physicians. In addition, protein catabolic rates and selected clinical outcome criteria were assessed. Weekly KT/V urea correlated with weekly creatinine clearance (r = 0.50) as well as with the protein catabolic rate (r = 0.45). Patients were arbitrarily divided into three groups based on KT/V urea measurements. Thirty percent of the patients had weekly KT/Vs < or = 1.4, 41% had KT/Vs between 1.5 and 1.8, and 29% had weekly KT/Vs > or = 1.9. Significant differences were not noted in hospitalization rates, erythropoietin doses, or serum albumin concentrations in patients with KT/Vs < or = 1.4 and in patients with KT/Vs > or = 1.9. Peritonitis rates were highest in the patients with KT/V > or = 1.9. Therefore, in patients randomly selected from our large CAPD center, 30% of the patients had weekly KT/V urea measurements < or = 1.4. The clinical significance of this finding remains uncertain.

Pseudomonas peritonitis associated with continuous ambulatory peritoneal dialysis: a six-year study.

In a population of 214 patients on continuous ambulatory peritoneal dialysis (CAPD), 415 peritoneal infections occurred between 1980 and 1986. Fourteen of these infectious events were caused by Pseudomonas aeruginosa (3.4%). None of those patients with P aeruginosa peritonitis were cured by medical therapy alone. Peritoneal catheter removal was necessary to achieve resolution of the infection. Significant patient morbidity from Pseudomonas infection included loss of peritoneal space for further dialysis and abscess formation. Our data suggests that prompt catheter removal should be seriously considered for chronic ambulatory peritoneal dialysis patients who develop P aeruginosa peritonitis.