Simultaneous measurement of peritoneal glucose and free water osmotic conductances.

Ultrafiltration (UF) failure is one of the most important causes of long-term peritoneal dialysis (PD) failure in patients. Osmotic forces acting across small and ultra-small pores generate a UF with solutes through the small pore and free water transport (FWT) through the ultra-small pore. The ability of glucose to exert an osmotic pressure sufficient to cause UF is the so-called 'osmotic conductance to glucose' (OCG) of the peritoneal membrane. Our study proposes a simple method to determine both the OCG and FWT. In 50 patients on PD, a Double Mini-Peritoneal Equilibration Test (Double Mini-PET), consisting of two Mini-PET, was performed consecutively. A solution of 1.36% glucose was used for the first test, whereas a solution of 3.86% glucose was used for the second test. The sodium removal values and the differences in UF between the two tests were used to calculate FWT and the OCG. Patients with UF failure showed significant reductions not only in the OCG and the FWT but also of UF of small pores. The Double Mini-PET is simple, fast, and could become useful to evaluate patients on PD in everyday clinical practice.

[Antimicrobial agents for preventing peritonitis in peritoneal dialysis: guideline from the Italian Society of Nephrology]. / Strategie antimicrobiche per la prevenzione delle peritoniti in dialisi peritoneale: Linea Guida.

BACKGROUND: The current 3rd edition of the Italian Society of Nephrology guidelines has been drawn up to summarize evidence of key intervention issues on the basis of systematic reviews (SR) of randomized trials (RCT) or RCT data only. The present guideline reports evidence of the use of antimicrobial agents for preventing peritonitis in peritoneal dialysis (PD). METHODS: SR of RCT and RCT on treatments aiming at preventing peritoneal dialysis peritonitis were identified referring to a Cochrane Library and Renal Health Library search (2005 update). Quality of SR and RCT was assessed according to current methodological standards. RESULTS: One SR and 19 RCT were found addressing this issue. Staphylococcus Aureus nasal carriage treatment with mupirocin reduces exit-site and tunnel infections but not peritonitis. Topical gentamicin treatment on the exit site reduces Staphylococcus Aureus infection and peritonitis incidence. Intravenous antibiotics administration prior to catheter placement significantly reduces the risk of early peritonitis but not exit-site and tunnel infections. Oral nistatin associated with antibiotic treatment significantly reduces the incidence of Candida peritonitis. No other prophylaxis measure seems to be effective based on available evidence. CONCLUSION: In patients on peritoneal dialysis current evidence supports the hypothesis that topical mupirocin reduces the risk of Staphylococcus Aureus peritonitis, intravenous antibiotics prior to catheter placement prevent the risk of early peritonitis, and oral nistatin reduces the risk of Candida peritonitis. Further studies are necessary to test the effectiveness of other interventions.

[Catheter-related interventions to prevent peritonitis in peritoneal dialysis: guideline from the Italian Society of Nephrology]. / Strategie correlate al catetere per la prevenzione delle peritoniti in dialisi peritoneale: Linea Guida.

BACKGROUND: The current 3rd edition of the Italian Society of Nephrology guidelines has been drawn up to summarize evidence of key intervention issues on the basis of systematic reviews (SR) of randomized trials (RCT) or RCT data only. The present guideline report evidence of catheter-related interventions to prevent peritonitis in peritoneal dialysis (PD). METHODS: SR of RCT and RCT of catheter-related interventions to prevent peritonitis in PD were identified referring to a Cochrane Library and Renal Health Library search (2005 update). RESULTS: Two SR and 17 RCT were found addressing this issue. Methodological quality of available RCT was suboptimal according to current methodological standards. The use of the Y-set systems with disinfectant and the twin-bag systems was associated with a significantly lower risk of peritonitis. No other catheter-related interventions were found to be of proven efficacy in preventing the risk of peritonitis and exit-site/tunnel infection in PD patients. CONCLUSION: It is still unknown whether any particular PD catheter design or implantation technique are effective to prevent peritonitis in patients on peritoneal dialysis. Further studies are necessary to test the effectiveness of new interventions.

[Treating peritonitis in peritoneal dialysis: guideline from the Italian Society of Nephrology]. / Terapia iniziale della peritonite in dialisi peritoneale: Linea Guida.

BACKGROUND: The current 3rd edition of the Italian Society of Nephrology guidelines has been drawn up to summarize evidence of key intervention issues on the basis of systematic reviews (SR) of randomized trials (RCT) or RCT data only. The present guideline reports evidence of interventions to treat peritonitis in peritoneal dialysis (PD). METHODS: SR of RCT and RCT on treatments for peritoneal dialysis peritonitis were identified referring to a Cochrane Library and Renal Health Library search (2005 update). Quality of SR and RCT was assessed according to current methodological standards. RESULTS: Thirty-six RCT were found addressing the intervention issue. Vancomycin or first generation cephalosporins may be used for treating peritoneal dialysis peritonitis due to Gram-positive agents. Third-generation cephalosporins or amino-glycosides may be used for Gram-negative agents peritonitis. Association of first-generation cephalosporins and agents against Gram-negative bacteria via the intraperitoneal route represents the most frequently used approach. Intraperitoneal administration of antibiotic agents is the most effective treatment of peritoneal dialysis peritonitis. Intermittent administration may be preferred to continuous administration of antibiotic agents in peritoneal dialysis peritonitis. CONCLUSION: In peritoneal dialysis peritonitis current evidence supports the hypothesis that intraperitoneal administration of antibiotics agents and intermittent administration may be preferred to other routes of administration and continuous administration. Further studies are necessary to test this hypothesis in selected patient populations.

Peritoneal transport assessment by peritoneal equilibration test with 3.86% glucose: a long-term prospective evaluation.

The peritoneal equilibration test (PET) with 3.86% glucose concentration (3.86%-PET) has been suggested to be more useful than the standard 2.27%-PET in peritoneal dialysis (PD), but no longitudinal data for 3.86%-PET are currently available. A total of 242 3.86%-PETs were performed in 95 incident PD patients, who underwent the first test during the first year of treatment and then once a year. The classical parameters of peritoneal transport, such as peritoneal ultrafiltration (UF), D/D(0), and D/P(Creat), were analyzed. In addition, the absolute dip of dialysate sodium concentration (DeltaD(Na)), as an expression of sodium sieving, was studied. D/D(0) was stable, and a progressive decrease in UF was observed after the second PET, whereas D/P(Creat) firstly increased and then stabilized. DeltaD(Na) was the only parameter showing a progressive decrease over time. On univariate analysis, D/D(0) and DeltaD(Na) were found to be significantly associated with the risk of developing UF failure (risk ratio (RR) 0.987 (0.973-0.999), P=0.04, and RR 0.768 (0.624-0.933), P=0.007, respectively), but on multivariate analysis only DeltaD(Na) showed an independent association with the risk of developing UF failure (RR 0.797 (0.649-0.965), P=0.020). UF, D/D(0), and D/P(Creat) changed only in those patients developing UF failure, reflecting increased membrane permeability, whereas DeltaD(Na) significantly decreased in all patients. The 3.86%-PET allows a more complete study of peritoneal membrane transport than the standard 2.27%-PET. DeltaD(Na) shows a constant and significant reduction over time and is the only factor independently predicting the risk of developing UF failure in PD patients.

[The Socisin Mailing List: assessment at 12 months]. / La Mailing List Socisin: bilancio del 1 anno di attività.

BACKGROUND: This Mailing List (ML) is an automatic e-mail distribution system on a specific topic. The medical world uses MLs to keep specialists in touch, however far apart they may be. The Socisin ML, circulated for discussion among members of the Italian Society of Nephrology (SIN), was one year old on 30th September 2001. This paper reports on its first 12 months in use. METHODS: We analysed all data on the number of messages received, accepted and rejected, their characteristics and authors, as well as the numbers subscribing and unsubscribing to the list. RESULTS: The number of messages were 391, 171 (43.7%) of them related to genuine scientific discussion. The proportional weight of the topics discussed was: peritoneal dialysis 51% (n=88), hemodialysis 40% (n=68), nephropathology 8% (n=13), transplantation 1% (n=2). Twenty-five congresses, symposiums and meetings were presented and one research trial was implemented after its presentation to the members. Compared with the Nephrology international ML, the number of messages were 13.5% (391/2907). Membership increased from 336 to 443 (+32%). There were 124 new subscribers and 17 unsubscribers (+107). During this first year, 146 nephrologists sent at least one message to the ML. DISCUSSION: Our objective is to extend the number of participants, make the discussion increasingly scientific, and cover all aspects of nephrology. The Socisin ML will certainly become very valuable to Italian nephrologists provided it continues to grow and keeps to the rules pertinent to such tools and the spirit of a "common" project.

Day-to-day variability of adequacy indexes in peritoneal dialysis.

BACKGROUND: The achievement of dialysis adequacy targets in peritoneal dialysis (PD) is assessed by the calculation of the Kt/V and creatinine clearance (C(Cr)) obtained by collecting dialysate and urine, usually two or three times a year. Prescription decisions are based on such adequacy assessments, regardless of any variability in the single measurements. The aim of our study was to assess the day-to-day variability of common dialysis adequacy parameters and to evaluate its impact on the adequacy indexes in PD. METHODS: Twenty-four patients (14 CAPD, 10 APD) at two centres were studied by means of a triple dialysate and urine collection for a period of 1 week. Variability in the findings for a given patient was expressed by the coefficient of variation (CV%) calculated for peritoneal (p), renal, and total (tot) adequacy parameters. The target Kt/V and C(Cr) values were recalculated on the basis of variability. RESULTS: Kt/V was less variable (CV 4.0 and 4.4% for peritoneal Kt/V (pKt/V) and total Kt/V (totKt/V) respectively) than C(Cr) (4.7 and 6.0% for peritoneal creatinine clearance (pC(Cr)) and total creatinine clearance (totC(Cr)) respectively) and proved to be a more reliable indicator of adequacy in terms of the CV. Both variability parameters became worse if renal clearance was added to peritoneal clearance. CV in APD proved to be no different from CAPD for all the parameters considered. In our centres dialysis adequacy target correction for variability provided safe values for weekly Kt/V (pKt/V=1.78-2.10 and totKt/V=1.82-2.15 target 1.7-2.0) and C(Cr)/1.73 (pC(Cr)=53.7-64.4 l and totC(Cr)=55.1-66.1 l; target 50-60 l). CONCLUSIONS: Evaluating the adequacy of PD by means of a single measurement should take into account the weekly variability as demonstrated by a triple dialysate and urine collection. Standard adequacy targets can be corrected to allow for variability. Thus one can obtain safe values for prescription decisions based on a single collection result.

Efficacy of corticosteroid therapy on cerebral gummas: risks and implications.

Complete resolution of a cerebral gumma can take place after massive corticosteroid treatment. Such a result in patients not known as syphilitic can be misleading and hamper the identification of the true nature of the lesion.

Symptoms in hemodialysis patients and their relationship with biochemical and demographic parameters.

Symptoms can markedly influence the hemodialysis patients well-being and quality of life. The aim of this paper is to study the frequency of symptoms at home and how these relate to biochemical and treatment variables. Seventy-three hemodialysis patients were questioned on the absence, occasional presence or daily recurrence (score = 0, 1, 2) of 14 symptoms and a record was made of their biochemical parameters, age, time on treatment and KtIV as a function of each symptom. The following relationships were detected: thirst with high Osm and BUN; asthenia with old age and hypoalbuminemia; insomnia with hypercalcemia; hypersomnia with hypoxemia and hypernatremia; anorexia with hypokalemia; dyspnea with old age, hypernatremia and hypokalemia; dysgeusia with hypoxemia; nausea with alkalemia, hypoxemia and low BUN; vomiting with alkalemia. Pruritus, arthralgia, restless legs syndrome, cramp and tremor showed no relationships. Monitoring acid-base balance and plasma electrolytes could help to alleviate symptoms and ameliorate quality of life of hemodialysis patients.

Continuous tidal peritoneal dialysis (CTPD) prescription and adequacy targets.

NKF-DOQI guidelines suggest a Kt/V value of 2.1 and a creatinine clearance (CRCL) value of 63 L/1.73 m2 of body surface area per week as minimum targets in continuous cycling peritoneal dialysis (CCPD). Those targets are obtained by adapting the CAPD guidelines. The aim of our study was to verify the possibility of reaching the suggested targets with continuous tidal peritoneal dialysis (CTPD) and to check target modification in this automated treatment. Eight anuric patients underwent four consecutive CTPD sessions with increasing total prescribed volumes (17 L, 22 L, 27 L, and 32 L; night 9 h; fill 2.2 L; tidal 75%, day 2 dwells). The Kt/V increase was significant (P = 0.012), unlike that of CRCL, with larger volumes. Two patients did not reach target Kt/V, and four did not reach target CRCL. The volume normalized for 1.73 m2 corresponding to DOQI targets was 19.6 +/- 2.6 L for Kt/V and 20.2 +/- 2.4 for CRCL. The overall Kt/V was 2.29 +/- 0.66 and CRCL was 57.3 +/- 16.5 L/1.73 m2. CRCL/Kt/V overall ratio was 25.6 +/- 4.7 and significantly different from the target ratio (63/2.1 = 30, P < 0.001). The CRCL/Kt/V ratio showed a significant decrease with larger volumes (P = 0.001, linear trend P < 0.001). Adequacy targets can be reached only in some patients on CTPD even with high dialysis volumes. The changes in the CRCL/Kt/V ratio in relation to dialysis volume can be considered for adaptation and evaluation of adequacy targets in automated treatments.

Compliance study in peritoneal dialysis using PD Adequest software.

Poor compliance in peritoneal dialysis (PD) is a significant cause of dropout and morbidity. PD Adequest software, which, through a mathematical model, predicts the effect of the dialysis prescription on the basis of the peritoneal transport, may be used to identify the noncompliant patient. Fifty patients from two dialysis centers, aged 65.9 +/- 1.5 years and on PD for 28.6 +/- 4.7 months, were studied. A peritoneal equilibration test (PET) was carried out and 24-hour urine and dialysate were collected. Total weekly creatinine clearance (CrCl, L/week/1.73 m2) was calculated, as well as the glomerular filtration rate [(GFR), mL/min, mean CrCl and urea nitrogen clearance (UNCI)]. The dialytic schedules used were then introduced into the program and the parameters were recalculated using the software model. Nine patients considered noncompliant from their case histories were used to assess the differences of reference between expected and measured values. The control group was significantly different from the noncompliant group in the percentage of the CrCl and the serum creatinine (sCR) differences. The noncompliance threshold value was calculated from the mean of the lower 95% confidence interval of the compliant group and the higher one of the noncompliant group (-5.3%) for CrCl and vice versa for sCR (+10%), which behaved to the contrary. Reassessing the patients, 11 (22%) were identified as probably noncompliant.