Periodontal disease in chronic kidney disease and end-stage renal disease patients: a review.

Periodontal disease is a chronic inflammatory disorder and being so it has been associated with accelerated atherosclerosis and malnutrition. Cardiovascular diseases are the leading cause of mortality in chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients [National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases: Annual Data Report, 2010]. A recent scientific statement released by the American Heart Association [Lockhart et al.: Circulation 2012;125:2520-2544] claims that, even though evidence exists to believe that periodontal interventions result in a reduction in systemic inflammation and endothelial dysfunction, there is little evidence that those interventions prevent atherosclerotic vascular disease or modify the outcomes. In this review, we discuss the periodontal findings and their association with an increased prevalence of inflammatory markers and cardiovascular mortality in ESRD patients and CKD.

Predictors of hospitalization in patients on peritoneal dialysis: the Missouri experience.

BACKGROUND: We analyzed a large number of demographic and biochemical variables to identify predictors of hospitalization in subjects on peritoneal dialysis (PD). METHODS: All patients initiated on PD at our center from January 1990 through December 1999 were included. The following variables at the initiation of PD were included: demographics, clinical data, nutritional and adequacy parameters, transport characteristics, and various co-morbidities. Co-morbidities were graded for severity using a modified version of the Index of Coexistent Disease. Variables included during the course of PD consisted of weighted time average of a number of laboratory, adequacy, and nutritional parameters along with the number of peritonitis episodes per year. Stepwise linear regression was used following a univariate screening procedure to identify independent predictors of the outcome of hospitalization days per month on PD. RESULTS: The subject population consisted of 191 subjects (105 men, 86 women; 180 Caucasians, 10 African-American, 1 Asian). The mean age was 61 +/- 13 (SD) years and mean duration of follow-up was 21 +/- 18 months. The baseline variable analysis revealed that the presence of partner to perform PD predicted increased hospitalization (p < 0.0001). Additionally, the presence and severity of peripheral vascular disease and residual renal Kt/V at baseline (negative association) predicted increased hospitalization. In the analyses of ongoing variables, stepwise linear regression solely identified weighted time average albumin as a strong negative predictor of hospitalization (p < 0.0001). CONCLUSION: A comprehensive analysis of a large number of variables revealed that serum albumin during the course of PD (negative association) and the need for partner to perform PD strongly predicted increased hospitalization in PD subjects.

Peritoneal dialysis or hemodialysis? A dilemma for the nephrologist.

Selection of the initial dialysis modality is crucial in the treatment of end-stage renal disease (ESRD) patients. Several patient- and physician-related factors play important roles in the decision between peritoneal dialysis (PD) and hemodialysis (HD). Although HD is the most common dialysis modality in the United States, in some studies PD has shown a survival advantage over HD, at least in the first 2 years of dialysis treatment, especially in non-diabetic patients and in young patients with diabetes. Other advantages accrue to early PD use in many patients. An integrated care approach with "healthy start" and PD as the initial renal replacement therapy, followed by timely transfer to HD once complications arise, may improve the long-term survival of ESRD patients.

MIA syndrome in peritoneal dialysis: prevention and treatment.

Malnutrition, inflammation and atherosclerosis are prevalent in end stage renal disease and constitute the Malnutrition-Inflammation-Atherosclerosis Syndrome. The syndrome is associated with high cardiovascular mortality and accounts for most of the premature deaths in peritoneal dialysis patients. Presence of elevated C-reactive protein levels correlates with malnutrition, decreased fluid removal and mortality in these patients. Early recognition of the syndrome is important to identify high risk patients. Nutritional support, changes in dialysis and drug therapy may decrease the cardiovascular morbidity and mortality.

Automated peritoneal dialysis - indications and management.

Automated peritoneal dialysis (APD) use has increased considerably in the last decade, and its growth has been mainly driven by patient preference and development of new, simpler cyclers. Careful management of the APD prescription can result in adequate solute and fluid removal in vast majority of patients, even anuric and large patients. So far, there are no convincing data that peritonitis rates, decline in residual renal function, protein losses, patient and technique survival, are different for APD and continuous ambulatory peritoneal dialysis (CAPD). APD has the major advantage of allowing positive changes in the life-style of end stage renal disease patients.

Rates of continuous ambulatory peritoneal dialysis-associated peritonitis at the University of Missouri.

Peritoneal dialysis (PD)-associated peritonitis contributes significantly to morbidity and modalityfailure. The number of patients on PD is declining in Western countries, and peritonitis is a potential deterrent to the therapy. Here, we present a clinically significant decline in the rate of peritonitis at a single center over a 28-year period, with current rates significantly lower than the national average, and we review several factors that have contributed to those outcomes. Peritonitis and duration of follow-up have been recorded for all patients followed in our program since 1977. Introduction of important technological changes into the program were also recorded. All peritonitis rates are expressed as episodes/patient-year or episodes/n patient-months. Data are summarized for each calendar year since 1977. We followed 682 patients for a total follow-up duration of 15,435 patient-months. Glass bottles were changed to plastic bags in 1978. Straight connecting tubes were replaced by Y-sets in 1988. The presternal dialysis catheter was introduced in 1991 and has been the primary PD access since 1995. The peritonitis rate in 1977 was 5.8 episodes/patient-year, and that rate has progressively declined over the past 27 years to 0.35 episodes/patient-year in 2004. Technical improvements that contributed to the decline in overall peritonitis rates have been adopted nationwide. The largest improvement occurred with the switch from glass bottles to plastic bags, and to the closed-system Y-set that incorporated the flush-before-fill principle. Advances in catheter technology have also played a key role. Quality improvement in the program and long years of experience in overall care of PD patients are significant factors that cannot be measured quantitatively. Improvements have been made to exit-site care protocols, to exit-site evaluation and diagnosis, and to treatment strategies. Patient education and training in catheter care remain the important factor in a PD program. Many factors have contributed to the reduction of PD-associated peritonitis rates at our center Improved connectology, catheter care, and patient education play key roles in the reduction of peritonitis.

National Kidney Foundation Council on Renal Nutrition survey: past-present clinical practices and future strategic planning.

Early nutritional intervention is thought to play a major role in the preservation of renal function and the overall wellbeing in the renal patient. In preparation for renal replacement therapy (RRT), a consultation with the renal nutritionist to establish a diet consistent with the existing diagnosis may increase the likelihood of reducing cardiovascular risk factors, preventing malnutrition and anemia, and slowing the progression of renal disease, all of which can contribute to positive patient outcomes. In a 1999 United States Renal Data System survey of 3,468 new dialysis patients, 46% indicated that they had not consulted with a dietitian before the initiation of dialysis. To help with establishing education programs, determine staffing guidelines, and planning future endeavors, the National Kidney Foundation Council on Renal Nutrition conducted a survey of their 1,748 members. The survey was designed to assess the current demographic profile and clinical practice elements of practicing renal dietitians. Surveys were distributed as a section of the 1999-2000 winter issue of the CRN Quarterly Newsletter, with 353 of the members responding. Information collected pertained to patient care settings, number of facilities covered, patient age, patient treatment modalities, dietitian contact hours required to effectively educate pre-end-stage renal disease patients on a low-protein diet and to ensure optimal nutrition status for the chronic kidney disease patients. The dietitians of this cohort had practiced dietetics for 14.5 +/- 8.6 years and renal nutrition for 9.15 +/- 6.9 years. The survey data showed a discrepancy between what the clinical practices were in 1999 and what the current recommendations are, based on the Kidney Disease Outcomes Quality Initiatives (K/DOQI) Clinical Practice Guidelines.

Retrospective evaluation of renal kt/V(urea) at the initiation of long-term peritoneal dialysis at the University of Missouri: relationships to longitudinal nutritional status on peritoneal dialysis.

The purpose of this study was to examine the impact of low levels of residual renal function (RRF) on nutritional status in end-stage renal disease patients starting peritoneal dialysis (PD) at baseline and after a year on dialysis. We conducted a single center retrospective analysis of 116 patients who started long-term PD in a university teaching hospital from 1989 to 1998 and were followed for 1 year. Patients were divided into four equal groups according to their initial renal Kt/V(urea) (L/week) levels at the start of PD and followed for 1 year. There were no interventions. The relationship between dialysis adequacy (renal and total Kt/V(urea)) and nutritional status was studied at baseline and at 1 year. Baseline data for patients who survived were compared with the baseline data of those who died and with their own 1 year data. At baseline, the mean serum albumin (3.31 g/dl, p < 0.0001) and lean body mass (47.20% body weight, p < 0.04) of group 1 were significantly lower than in groups 2, 3, and 4. Levels of normalized protein equivalent of nitrogen appearance (nPNA) were significantly lower in group 1 than in groups 3 and 4 (p < 0.005). Although group 1 patients showed trends toward improvement in nutritional parameters, they never caught up with the other groups. At the end of 1 year, the lower total Kt/V(urea) in group 1, with the lowest RRF, was associated with the lowest mean values for nutritional status and the highest death rate. Comparison of baseline and 1 year data of survivors showed that nutritional status improved or remained stable in groups 3 and 4, who exceeded the minimum recommended adequacy targets as per Dialysis Outcome Quality Initiative criteria (mean 12 month total Kt/V(urea) 2.18 and 2.58, respectively). Comparison of baseline data of survivors and those who died showed that patients who died had lower mean values for serum albumin, nPNA, lean body mass, and body weight across all groups. Low RRF at the start of dialysis is associated with poor nutritional status. Also, patients who start dialysis with low RRF and poor nutritional status do not have significantly improved nutritional status even after 1 year on dialysis.

Utilization of PD modalities: evolution.

In the early 1960s, peritoneal dialysis (PD) was introduced as a form of long-term maintenance therapy in patients with end-stage renal disease (ESRD). We have come a long way since. Increasing understanding of peritoneal kinetic behavior, its innovative manipulation to meet patient needs, critical monitoring of clinical outcomes, and parallel development in technology have all contributed to the worldwide success of the therapy over the past four decades. In this article we review the evolution of the various PD modalities in the context of these factors.

1975 to 1984--an important decade for peritoneal dialysis: memories with personal anecdotes.

That decade, 1975 to 1984, saw many important events in the history of PD, including (1) the beginnings of CAPD; (2) the performance in Canada of CAPD with solutions in bags; (3) the First International Peritoneal Dialysis Symposium, in Mexico, preceding all the symposia and congresses to follow; (4) the approval of solutions in bags and CAPD Medicare reimbursement in the USA; (5) the start of the NIH CAPD Registry, probably setting the groundwork for the USRDS; (6) the First Annual CAPD Conference, beginning 23 years of consecutive conferences; (7) the start of the Peritoneal Dialysis Bulletin, which later became Peritoneal Dialysis International; and (8) the formation of the ISPD. One hopes those caring for patients on chronic PD will remember the ideas and hopes of this period and build on them into the distant future. In my opinion, the new ideas, the clinical and laboratory studies, and the experiences shared during this exciting time not only advanced PD and its results, but also had a positive impact on our understanding of uremia and improved the quality of care and results obtained with all renal replacement therapies.

High peritoneal transport: a blessing or curse?

High transporters are defined based on the peritoneal equilibration test. Peritoneal transport rate changes over time, inflammation and angiogenesis affecting the total pore area. Factors influencing the neovascularization process are described. High transporters have distinctive clinical and laboratory features. The incidence of high transporters varies among different populations. Unfortunately, high transporters have the worst clinical outcomes. Mechanisms proposed to explain the adverse prognosis--including hypoalbuminemia, chronic fluid overload, malnutrition, and chronic inflammation--are discussed. We suggest dividing baseline high transporters into two groups: "sick" and "healthy" high transporters. The two types of high transporters have different baseline characteristics and different clinical outcomes. Hopefully, further studies will better define the appearance of the two groups of high transporters.

An analysis of dialysis training in the United States and Canada.

BACKGROUND: Because the prevalence of end-stage renal disease (ESRD) has progressively increased in both the United States and Canada, patients with ESRD are likely to constitute progressively larger proportions of nephrology practices. METHODS: We mailed a questionnaire to US and Canadian nephrology program directors to determine methods used in dialysis training; 53% of US and 73% of Canadian programs responded. RESULTS: Training programs in the United States enrolled a larger median number of fellows and had a lower median faculty-fellow ratio compared with programs in Canada. However, the availability of faculty in providing training in the care of patients undergoing maintenance hemodialysis (MHD) or chronic peritoneal dialysis (CPD) was similar in both countries. There were wide variations in availability of patients in both the United States and Canada. US training programs offered trainees significantly lower numbers of MHD and CPD patients; 29% of US training programs had less than five CPD patients per fellow. Similarly, there were wide variations in the amount of time trainees spent providing care to MHD and CPD patients; in 14% of US training programs, fellows spent less than 5% of their time receiving training for patients undergoing CPD. Only a small proportion of training programs had faculty resources or ensured training for fellows in the placement of percutaneous tunneled venous hemodialysis catheters or peritoneal dialysis catheters. CONCLUSIONS: To conclude, there are wide variations in dialysis training in both the United States and Canada. This survey raises concerns that many US training programs either do not have an appropriate number of CPD patients or do not allocate appropriate time to ensure the preparedness of fellows in providing independent care for patients with ESRD undergoing CPD.

The relationship between urine osmolality and specific gravity.

BACKGROUND: In general, there is a good correlation between the specific gravity and osmolality of a urine sample. In certain clinical conditions, such as uncontrolled diabetes mellitus, nephrotic syndrome, after the administration of intravenous radiocontrast material or saline diuresis, dependence upon specific gravity for determining the concentrating ability will result in over- or underestimation. METHODS: We studied the relationship between specific gravity and osmolality in vitro with simulated urines of varying composition. Urine samples from patients with different clinical conditions were also analyzed. RESULTS: The in vitro curves for sodium chloride, urea, creatinine, glucose, contrast dye, and albumin were plotted (specific gravity versus osmolality). We found a linear correlation between the specific gravity and osmolality of the 6 substances that were studied and for their combinations. The urine samples obtained from patients with different clinical conditions documented that reliance on specific gravity could over- or underestimate the urine osmolality. CONCLUSIONS: We concluded that in those clinical conditions, urine osmolality should always be determined and it should not be estimated based on specific gravity.