Effect of fluid and sodium removal on mortality in peritoneal dialysis patients.

UNLABELLED: Effect of fluid and sodium removal on mortality in peritoneal dialysis patients. BACKGROUND: Adequacy of peritoneal dialysis (PD) traditionally is assessed using Kt/V(urea) and total creatinine clearance (TCC). However, this approach underestimates the importance of fluid and sodium removal. The aim of this study was to determine the effect of fluid and sodium removal on morbidity and mortality in PD patients. METHODS: One hundred twenty-five PD patients were monitored for three years from the beginning of the treatment. The effects of demographic features, comorbidity, peritonitis rate, blood pressure, medications, blood biochemistry, peritoneal membrane transport characteristics, residual renal function (RRF), Kt/V(urea), TCC, normalized protein nitrogen appearance (nPNA), and removal of sodium and fluid on mortality were evaluated. Total and cardiovascular hospitalization rates were also recorded. A Cox proportional hazards model was used to determine factors predicting mortality. RESULTS: In the Cox model, comorbidity, total sodium and fluid removals, hypertensive status, serum creatinine, and RRF were independent factors affecting survival. In contrast, Kt/V(urea) or TCC did not affect the adjusted survivals. Total sodium and fluid removal and hypertensive status also significantly influenced the hospitalization rate. Systolic and diastolic blood pressures were negatively correlated with total fluid (P < 0.001) and sodium removal (P < 0.001). CONCLUSIONS: Together, these findings suggest that removal of sodium and fluid is a predictor of mortality in PD patients, whereas Kt/V(urea) and TCC are not factors. Adequate fluid and sodium balance is crucial for the management of patients on PD.

Recognition of neurocognitive dysfunction in chronic hemodialysis patients.

We sought to determine the prevalence, recognition, and consequences of mental impairment among chronic hemodialysis patients. We administered the Mini Mental Status Exam (MMSE), a brief validated method for assessing cognitive mental status that is commonly used by clinicians, to 84 patients from our dialysis units. To determine the clinical implications of mental impairment, we obtained Kt/V, albumin, protein catabolic rate, blood pressure, and hematocrit values. We found that 21% of subjects had mild mental impairment (MMSE 18 to 23) and that 11% had moderate-severe mental impairment (MMSE 0 to 17). We found no relationship between MMSE score and years on dialysis, Kt/V value, hematocrit value, or erythropoietin use. On univariate analysis, MMSE score was associated with albumin, protein catabolic rate, inter-dialytic weight gain, number of co-morbid conditions, number of hospitalizations. Outcomes on univariate analysis were further analyzed by multivariate analysis. There was an independent relationship between decrement in MMSE score and lower protein catabolic rate and increased hospitalization number and number of co-morbid conditions. Based on our findings, we recommend that clinicians routinely screen hemodialysis patients for mental impairment and target impaired patients for interventions to improve mental status and associated adverse outcomes.

Comparison of the effects of hospitalization and antibiotic usage on the aerobic intestinal flora.

Antimicrobial resistance among bacteria has arisen ever since antimicrobial agents were introduced in the clinic. Unfortunately, it seems that resistance is now emerging at a more rapid rate than ever before, as a consequence of the widespread use of antimicrobial agents. The spread of these multiresistant microorganisms is an increasing threat in many countries. The human intestinal flora is a huge potential reservoir of resistant microorganisms. Antimicrobial resistance in clinical isolates may cause serious infections and treatment failure, and lead to the use of higher doses or more toxic alternative drugs. This study was planned so as to compare the effects of hospitalization and antibiotic usage on the aerobic intestinal flora and included 43 hospitalized adult patients without any previous history of hospitalization and antibiotic usage during the last 30 d. Patients were divided according to their antimicrobial therapy, into treated and untreated groups. The individual use of antimicrobials was recorded. Antibiotic usage was found to be more effective on the aerobic intestinal flora compared with hospitalization without such medication.

Remission of nephrotic syndrome after removal of localized Castleman's disease.

Renal complications of Castleman's disease are uncommon. Among the various renal disorders, including mesangial proliferative glomerulonephritis, membranous glomerulonephritis, and minimal change disease, nephrotic syndrome attributable to renal amyloidosis is very rarely reported. We report a case of mixed type of localized Castleman's disease complicated with nephrotic syndrome. Renal biopsy was performed. The deposition of AA amyloidosis was shown. After the removal of two mesenteric lymphoid masses, the proteinuria was gradually decreased and disappeared. Renal biopsy was repeated after 14 months, and, despite complete remission of nephrotic syndrome, no regression in amyloid deposition was found.

The longitudinal effect of a single peritonitis episode on peritoneal membrane transport in CAPD patients.

OBJECTIVE: To evaluate the longitudinal effect of a single peritonitis episode on peritoneal membrane transport. DESIGN: A prospective longitudinal study. SETTING: Department of nephrology in a university hospital. PATIENTS: Eighteen continuous ambulatory peritoneal dialysis patients with peritonitis. METHODS: Peritoneal transport for low, middle, and high molecular weight (MW) solutes was evaluated by peritoneal equilibration test (PET). The first PET was performed on the day following the diagnosis of peritonitis. The test was repeated at weeks 1, 2, 4, 12, and 24 and the results were compared to baseline PET data obtained before peritonitis. In addition, dialysate CA125 concentration and leukocyte count were measured. RESULTS: During peritonitis there were significant increases in dialysate-to-plasma (D/P) ratios for all low, middle, and high MW solutes except potassium, and decreases in D4/D0 glucose ratio and ultrafiltration (UF) volume. Over the subsequent 2 weeks, solute transport gradually decreased to the baseline values then remained unchanged during follow-up. Although net UF volume demonstrated a similar course during the study, it did not completely return to the baseline value. No decrease in D/P sodium ratio was found at 60 minutes during the PET performed 24 weeks after peritonitis. The percent change in solute transport during peritonitis compared to baseline value was significantly correlated with a solute's MW (r = 0.776, p = 0.014). The slope of the regression line for D/P ratios versus MW, in double logarithmic scale, before peritonitis (-0.73 +/- 0.09) was steeper than the slope during peritonitis (-0.59 +/- 0.08). CONCLUSIONS: These findings indicate that a single peritonitis episode does not permanently affect peritoneal solute transport. However, the loss of net UF that accompanies peritonitis is not completely recovered, probably due to impairment of transcellular water transport. The transport changes associated with peritonitis may be due to the combined effect of increased effective peritoneal surface area and intrinsic permeability. Our findings suggest that the latter mechanism seems to be more important.

Carotid intima-media thickness and ACE-gene polymorphism in hemodialysis patients.

BACKGROUND: Carotid artery intima-media thickness (CIMT) has been used as a marker of atherosclerosis. An insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene is associated with various cardiovascular diseases. This study is aimed at evaluating early atherosclerotic involvement of carotid vessels and the relation to known risk factors and ACE gene I/D in hemodialysis (HD) patients. METHODS: We measured CIMT using high-resolution B-mode ultrasonography in 51 non-diabetic HD patients and in 70 age- and sex-matched healthy controls, and evaluated the factors influencing CIMT. An I/D polymorphism in intron 16 of the gene coding for ACE was analysed by polymerase chain reaction. RESULTS: The mean CIMT was significantly higher in HD patients than in healthy subjects (p<0.0001). In multiple regression analysis, independent risk factors for increased CIMT in HD patients were predialysis systolic blood pressure (p<0.001) and ACE D allele (p<0.01). CONCLUSIONS: The present data suggest that CIMT is enlarged in HD patients. The ACE gene seems to be a candidate for influencing the CIMT and might therefore be involved in an HD patient's predisposition to the development of atherosclerosis.

The impact of withdrawing ACE inhibitors on erythropoietin responsiveness and left ventricular hypertrophy in haemodialysis patients.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors have the capability of decreasing left ventricular mass index (LVMI) in chronic haemodialysis (HD) patients. On the other hand, recent reports provide conflicting information regarding the impact of ACE inhibitors on responsiveness to recombinant human erythropoietin (rHuEpo), and there are no data about the effect of withdrawing ACE inhibitors both on rHuEpo response and LVMI in HD patients. METHODS: ACE inhibitors were switched to another antihypertensive medication in 23 out of 68 patients in our HD unit who were receiving both rHuEpo and an ACE inhibitor for more than 1 year. Blood pressure at the pre- and post-dialysis phases, haematocrit levels and rHuEpo doses were determined at the end of the first and of the third years, and the LVMI was determined at the end of the third year. Statistical analyses were done in 15 patients in whom the study could be completed. RESULTS: The mean (+/-SD) haematocrit level was increased from 26.3+6.4% to 29.8+/-6.3% at the first year (P<0.05), and to 29.4+/-6.5% at the third year (P<0.05 vs before), while the mean dose of rHuEpo was decreased from 208.3+/-99.0 UI/kg/week to 141.0+/-91.8 at the first year (P=0.01), and to 141.4+/-81.0 at the third year (P=0.01 vs before). Administration of rHuEpo had been stopped in two patients at the end of the first year. The mean blood pressure level and the mean LVMI were not changed (P>0.05 vs before). There were no significant changes in dialysis parameters, iron status, plasma renin activities, and levels of aldosterone, intact parathyroid hormone, aluminum and erythropoietin. CONCLUSION: The findings of this small uncontrolled study indicate that withdrawal of ACE inhibitors in hypertensive chronic HD patients receiving rHuEpo may result in an increase in haematocrit level, and a decrease in dose of rHuEpo without any significant changes in the blood pressure level and LVMI. Controlled prospective studies are needed to clarify this issue.

Relationship of ambulatory blood pressure monitoring data to echocardiographic findings in haemodialysis patients.

BACKGROUND: The present study was performed to assess the value of ambulatory blood pressure monitoring (ABPM) in determining the adequacy of blood pressure (BP) control, and its relationship to echocardiographic findings in haemodialysis (HD) patients. METHODS: We studied 40 non-diabetic adult patients who had been on regular HD treatment for a median duration of 43 months. Twenty-four-hour ABPM was performed using a non-invasive ABP monitor (Pressurescan, ERKA). Casual BP (cBP) was defined as the average of two measurements obtained at two HD sessions, one preceding and one following the ABP recordings, and was calculated for both the predialysis and postdialysis phases. Two-dimensional and M-mode echocardiography were performed in each patient to determine interventricular septal thickness (IVS), left ventricular posterior wall thickness (LVPW), left ventricular fractional shortening (FS), and left ventricular mass index (LVMI). RESULTS: According to average 24-h BP levels, 50% of the patients had systolic hypertension (HT) (> 139 mmHg), and 72.5% had diastolic HT (> 87 mmHg), while only 25% had been diagnosed as HT by cBP measurements (P < 0.01 and P < 0.0001 respectively). Diurnal variation in BP was not present in about 80% of the patients. Echocardiography was normal in only four patients (10%). LVMI and LV wall thickness were correlated to ABPM data better than to cBP measurements. Using stepwise linear regression analysis, LVMI and IVS were positively correlated with systolic BP load (P < 0.0001 and P = 0.0001 respectively), and LVPW was positively correlated with night-time systolic BP level (P < 0.001). CONCLUSIONS: ABPM is necessary to assess the adequacy of BP control, and is well correlated to end-organ damage of HT in HD patients.