Automated and continuous ambulatory peritoneal dialysis have similar outcomes.

We compared survival and death-censored technique survival in patients on automated peritoneal dialysis (automated dialysis) or on continuous ambulatory peritoneal dialysis. All 4128 patients from the Australia and New Zealand Dialysis and Transplant Registry who started peritoneal dialysis over a 5-year period through March 2004 were included. Times to death and death-censored technique failure were analyzed by Cox proportional hazards models while a conditional risk set model computed technique failure. Compared to patients treated entirely with continuous ambulatory peritoneal dialysis, automated peritoneal dialysis patients were more likely to be young, Caucasian, have marginally lower body mass index, and were less likely to have baseline cardiovascular disease or diabetes. Using univariate and multivariate analysis, our study showed there were no significant differences in patient survival and death-censored technique failure between the two types of peritoneal dialysis modalities.

Increased end-stage diabetic nephropathy in Indo-Asian immigrants living in the Netherlands.

AIMS/HYPOTHESIS: We aimed to investigate the risk of end-stage diabetic nephropathy due to Type II (non-insulin-dependent) diabetes mellitus in Indo-Asian immigrants from Surinam. METHODS: A demographically based case-control study was carried out in Surinamese Indo-Asian immigrants and Dutch Caucasian subjects. All patients with end-stage diabetic nephropathy who had started dialysis between 1990 and 1998 were identified through a national registry of all patients entering a renal replacement program in the Netherlands. The general population of native Dutch and Surinamese Indo-Asians were considered the control subjects. RESULTS: Among Indo-Asian immigrants, the age adjusted relative risk of end-stage diabetic nephropathy was 38 (95 % CI 16 to 91) compared with the native Dutch population. The duration of diabetes until the start of dialysis treatment was similar in both ethnic groups, about 17 years. CONCLUSION/INTERPRETATION: The Indo-Asian subjects had a nearly 40-fold increase in the risk for end-stage diabetic nephropathy due to Type II diabetes, compared with the native Dutch population. This was higher than expected on the basis of the eightfold higher prevalence of diabetes in the Indo-Asian population. The similar duration of diabetes until the start of dialysis treatment in both ethnic groups supports the hypothesis of a higher incidence of diabetic nephropathy in the Indo-Asian diabetic population. Early and frequent screening for diabetes and microalbuminuria is recommended in Indo-Asian subjects.

[Protein restriction in diet therapy in chronic kidney insufficiency]. / Proteineinschränkung in der Ernährung bei chronischer Niereninsuffizienz.

Dietary protein restriction represents an important new development in the treatment of chronic kidney disease during the last ten years. The dogma that chronic renal failure is always progressive appears to be broken. In clinical practice this mode of therapy is now established in early stages of renal failure. The precise indications, however, remain to be discussed ['Are all patients with chronic renal failure candidates for low-protein diets?']. The pathophysiological background of the diets is only partly elucidated. The main problem with low-protein diets is the compliance of the patients which is frequently insufficient. Studies are underway to answer some of these remaining open questions. This review summarises the current views on practical aspects of low-protein diets in chronic renal failure, and arguments for a more widespread application of this physiologic therapy are presented.

Protein-restricted diets in chronic renal failure: a four year follow-up shows limited indications.

Several retrospective and prospective studies confirmed the beneficial effect of dietary protein restriction (DPR) on the downhill course of renal function in chronic kidney disease. The long-term results of this therapeutic modality may be different than the short-term effects. In our nephrology outpatient department, a prospective randomized trial has been in progress since April, 1982. In 1984, we reported a general beneficial effect of our diet after two years of follow-up. Two hundred and forty-eight patients with initial creatinine clearances between 10 and 60 ml/min entered the trial. Patients were stratified for sex, age and degree of renal insufficiency. One hundred and twenty-nine patients were randomly assigned to a DPR-group (0.4 to 0.6 g/kg/day); 118 patients to a control group. Patients on DPR visited the dietitian every three months during the first 24 months of the study; thereafter, as with the controls, the dietitian visits were only for specific needs. Urea excretion decreased significantly in DPR patients as a sign of good compliance and stayed at that level, even without frequent visits to the dietitian. Biochemical parameters showed no signs of malnutrition. Amino acid profiles were related to the degree of renal failure. The diet appeared to have a selective effect on the progression rate of renal failure: only patients with primary glomerular disease responded to the diet. Furthermore, there were striking intersex differences. Males showed a more rapid decline towards end-stage renal failure, but responded in a positive way to the diet, whereas female patients did not benefit from the dietary manipulation at all.(ABSTRACT TRUNCATED AT 250 WORDS)

Dietary protein restriction in chronic renal failure: an update.

In recent years dietary protein restriction (DPR) to slow down the progression rate of chronic renal disease has been a major field in nephrological science. In this update a brief historical overview is given, as well as a critical review regarding the now available data from clinical trials. Furthermore, the theoretical backgrounds of DPR are discussed. It is concluded that DPR has profound effects on the kidney. In certain diseases, especially primary glomerular disease, the beneficial effect seems proven. However, many questions remain to be answered, e.g. how to apply reliable statistics in chronic renal failure, how to obtain and monitor patient compliance, and the definition of the exact target group since the diet has a selective effect. Most of these questions will be answered in the coming years when data becomes available from large scale multicenter trials. Awaiting these results, proposals for the treatment with diet are made, based on the facts that are now to our knowledge.

Relationship between proteinuria and response to low protein diets early in chronic renal failure.

In a prospective, randomized trial on the use of protein-restricted diets in chronic renal failure the impact of the protein intake on proteinuria was investigated. Furthermore, the effect on the progression rate of renal disease in patients with low versus high proteinuria was assessed. It is concluded, firstly, that protein restriction reduces protein excretion substantially. Secondly, over 18 months follow-up, especially patients with low protein excretion appeared to respond to the diet. In patients with heavy proteinuria the diet might have beneficial effects in the long term.

Absence of diabetes in a rural West African population with a high carbohydrate/cassava diet.

1028 (99%) of the 1038 inhabitants of the West African village of Agbave and a random sample of 353 (12.4%) of the population of 2850 in Kati, another West African village, were screened for diabetes. Also recorded were their anthropometric data, dietary habits, possession of antibodies to malaria, and serum IgG concentrations. About 85% of the study population consumed cassava root at least once a day. The mean (SD) capillary random blood glucose concentration was 5.1 (1.1) mmol/l in men and 5.1 (0.6) in women. The mean (SD) body mass index was 20.2 (1.8) in men and 20.7 (2.3) in women. The mean blood glucose was similar whether cassava was consumed once daily, more than once daily, or less than once daily. None of the 1381 subjects examined had diabetes. This finding suggests that a high carbohydrate/cassava intake (84% of a mean daily supply of 1916 calories) combined with a low protein consumption (8% of caloric supply) does not cause diabetes. This does not support the World Health Organisation hypothesis that malnutrition-related diabetes exists, at least not in this West African rural population.

The pathology and pathogenesis of malignant atrophic papulosis (Degos' disease). A case study with reference to other vascular disorders.

The morphology and immunohistology in a case of malignant atrophic papulosis (Degos' disease), a rare vascular disorder of unknown etiology, are described. The vascular lesions affected middle class and small arteries and veins throughout the body and were histologically characterized by intimal proliferation in the absence of any appreciable inflammation. The lesions were categorized as early, intermediate or late. Early lesions consisted of cellular proliferation and edema of the intima with signs of immune complex deposition (IgM, C3). Thrombosis was occasionally present as a secondary phenomenon in the affected vessel segments. In intermediate lesions the edema decreased and smooth muscle proliferation became apparent. Late lesions consisted of acellular intimal sclerosis with hyalinization and narrowing or obliteration of the vascular lumen. The media of the vessels remained always intact. In comparing these features to the pathology and pathogenesis of other vascular disorders they resembled the vascular lesions in a murine model of lupus erythematodes in which also considerable intimal proliferation occurred with thrombotic occlusion, but without appreciable inflammation. The murine model is associated with sustained low levels of circulating immune complexes and it is tempting to assume the same for Degos' disease. The notion of an immune complex mediated non-inflammatory condition underlying this severe and often fatal vascular disorder of mainly young males may contribute to the eventual finding of a successful therapeutical regimen.

Renal reserve filtration capacity in patients with type 1 (insulin-dependent) diabetes mellitus.

Glomerular hyperfiltration is one of the factors held responsible for the development of diabetic nephropathy. A supranormal glomerular filtration rate (GFR) can be found in diabetic patients even when they are well controlled. Infusion of low-dose dopamine demonstrates that glomerular hyperfiltration in well-controlled insulin-dependent diabetic patients is not based on a predominant vasodilatation of the efferent arteriole. In the present study this is confirmed, since the dopamine-induced rise in GFR of control subjects (13.5% +/- 2.2) did not differ from that of patients with insulin-dependent diabetes mellitus (10.8% +/- 2.1). In animal studies it has been demonstrated that the increased GFR in diabetes mellitus is caused by a predominant decrease in resistance of the afferent arteriole. Protein loading and infusion of amino acids also increase GFR by dilatation of the afferent arteriole. Thus, protein loading or amino acid infusion may be used to test the existence of afferent vasodilatation. The present study investigates the effect of amino acid infusion on GFR of control subjects and insulin-dependent diabetic subjects. The amino acid-induced rise in GFR tended to be lower in the diabetic patients (6.9% +/- 2.8) compared with controls (13.2% +/- 2.7). Percentage amino acid-induced change in GFR appeared to decline with increasing baseline GFR in the diabetic subjects (r = -0.83; P less than 0.001). In controls, no such relationship was established (r = -0.22; n.s.). Our results suggest the existence of afferent vasodilatation in diabetic patients with a high GFR. The cause of this vasodilatation warrants further study.

Renal hemodynamics during separate and combined infusion of amino acids and dopamine.

Healthy volunteers (N = 9) and patients with varying degrees of renal insufficiency (N = 36) were given a low dose of dopamine and/or amino acids intravenously during a simultaneous measurement of the glomerular filtration rate and the effective renal plasma flow. Dopamine infusion led to a rise in the glomerular filtration rate and a fall in the filtration fraction. Infusion of amino acids was accompanied by an increase in the glomerular filtration rate while the filtration fraction remained unchanged or increased slightly. The highest values for the glomerular filtration were obtained during the combined infusion of amino acids and dopamine. A reserve in filtration capacity was not or hardly present in patients with moderate (GFR 30 to 90 mliter/min/1.73 M2) to severe (GFR less than 30 mliter/min/1.73 M2) renal insufficiency. We conclude that dopamine decreases total renal vascular resistance while amino acids mainly reduce the tone of afferent arterioles. As amino acids and dopamine seem to be additive in their effects on the glomerular filtration rate, we recommend the combined infusion of these two stimuli to measure renal reserve filtration capacity.

The effect of low-dose dopamine on renal haemodynamics in patients with type 1 (insulin-dependent) diabetes does not differ from normal individuals.

It is well known that patients with Type 1 (insulin-dependent) diabetes exhibit both increased glomerular filtration rate and effective renal plasma flow, which can be found even when these patients are well controlled. Usually this is attributed to a decrease in renal vascular resistance and/or to enlarged kidney size and glomerular volume. Among the factors which govern glomerular filtration rate, renal plasma flow is most important. Renal plasma flow increases if renal vascular resistance decreases. The latter might exist in insulin-dependent diabetes mellitus because of either a predominantly afferent or a predominantly efferent vasodilatation. Dopamine is an agent which causes predominantly efferent vasodilatation. Therefore, the effects of infusing a low dose of dopamine on glomerular filtration rate and effective renal plasma flow in 12 well-controlled patients with Type 1 (insulin-dependent) diabetes and 28 healthy volunteers were compared to investigate whether the increased glomerular filtration rate in Type 1 diabetes is caused by an efferent vasodilatation. The median increase in glomerular filtration rate during dopamine infusion amounted to 13.0% in diabetic patients and 12.5% in healthy control subjects (n.s.). It is concluded that the elevated glomerular filtration rate in well-controlled Type 1 diabetes is not caused by a predominantly efferent vasodilatation.

Effect of intravenous infusion of low-dose dopamine on renal function in normal individuals and in patients with renal disease.

A low dose of dopamine was infused in 28 normal volunteers and in 137 patients with varying degrees of renal insufficiency during a routine measurement of the glomerular filtration (GFR) and the effective renal plasma flow (ERPF). Dopamine infusion led to an increase in ERPF and GFR and to fall in the filtration fraction. The effect of dopamine on renal function was most pronounced if the baseline GFR was normal. However, healthy individuals showed greater increases in both ERPF and GFR than renal patients with a comparable baseline GFR. In renal patients no effect was observed if the baseline GFR was below 50 ml/min/1.73 m2. Firstly, it is concluded that already early in renal disease there exists a diminished reserve filtration capacity. Secondly, if the GFR is less than 50 ml/min/1.73 m2, the renal reserve filtration capacity seems to be exhausted.

Early protein restriction in chronic renal failure.

We performed a prospective randomised trial in 199 patients with various stages of renal failure. Stratified for sex, age and renal insufficiency, 105 patients were assigned to a protein (Pr)-restricted group (0.4-0.6g/kg/BW), and 94 to a control group. Pr-restriction led to a significant reduction in the excretion of urea, phosphate and protein. Survival of renal function was significantly better in Pr-restricted patients. Median serum creatinine concentration increased in the control group (p less than 0.05), but remained stable in Pr-restricted patients. We conclude that Pr-restriction retards, or even halts the progression of chronic renal failure.