Líquido peritoneal turbio acelular y uso de antagonistas del calcio en diálisis peritoneal / Turbid acellular peritoneal fluid and the use of calcium antagonists in peritoneal dialysis

El líquido peritoneal turbio acelular de etiología no infecciosa es una entidad poco frecuente en diálisis peritoneal y se caracteriza por una concentración elevada de triglicéridos en el líquido peritoneal. Las causas más comunes son las neoplasias, las obstrucciones linfáticas, las pancreatitis, los traumatismos y se ha relacionado también con el uso de algunos fármacos, como los antagonistas del calcio. Las series con un mayor número de casos se han comunicado en población asiática. Recientemente hemos diagnosticado en nuestro centro 4 casos de líquido peritoneal turbio acelular relacionado con el uso de antagonistas del calcio. Nos planteamos revisar las características principales de los casos y estudiar la relación del antagonista del calcio con los niveles de triglicéridos en el líquido peritoneal de los pacientes estables en diálisis peritoneal durante el año 2010. De los cuatro enfermos con líquido peritoneal turbio acelular, el 75 % eran varones y el 75 % estaban en tratamiento con manidipino; en todos los casos se resolvió el problema con la retirada del fármaco. Los niveles de triglicéridos medios fueron de 314 mg/dl. Los niveles medios de triglicéridos de 36 pacientes estables de diálisis peritoneal fueron de 8,1 mg/dl, con un intervalo entre 1 y 35 mg/dl. La media de triglicéridos en los pacientes con o sin tratamiento con antagonistas del calcio fue muy similar: 7,81 y 8,6 mg/dl, respectivamente. No se observaron diferencias en relación con el tipo de antagonista del calcio prescrito. En nuestra experiencia, creemos que los antagonistas del calcio deben ser considerados como causa de líquido peritoneal turbio acelular en los enfermos en diálisis peritoneal, en especial el manidipino. No consideramos útil la determinación de triglicéridos en el líquido peritoneal de los enfermos asintomáticos en tratamiento con antagonistas del calcio (AU)

Turbid acellular peritoneal fluid of a non-infectious aetiology is an uncommon entity in peritoneal dialysis and is characterised by a high concentration of triglycerides in the peritoneal fluid. The most common causes include cancer, lymphatic obstructions, pancreatitis, trauma, and even the use of certain medications such as calcium antagonists. The largest studies concerning this entity have been carried out in patients of Asian descent. We recently diagnosed 4 cases of turbid acellular peritoneal fluid at our institution in relation to the use of calcium antagonists. We reviewed the primary characteristics of these cases and examined the relationship between the use of calcium antagonists and triglyceride levels in the peritoneal fluid of stable patients on peritoneal dialysis during 2010. Of the four patients with turbid acellular peritoneal fluid, 75% were male and 75% were on treatment with manidipine; in all cases, the issue was resolved by suspending medication. Mean triglyceride levels were 314mg/dl. Mean triglyceride levels in 36 stable patients on peritoneal dialysis were 8.1mg/dl, with a range of 1-35mg/dl. Mean triglyceride levels in patients with and without calcium antagonist treatment were very similar, at 7.81mg/dl and 8.6mg/dl, respectively. We did not observe significant differences in terms of the type of calcium antagonist prescribed. In our experience, we believe that calcium antagonists should be considered as a cause of turbid acellular peritoneal fluid in patients on peritoneal dialysis, in particular manidipine. We do not find it useful to determine triglyceride levels in the peritoneal fluid of asymptomatic patients on treatment with calcium antagonists (AU)

Turbid acellular peritoneal fluid and the use of calcium antagonists in peritoneal dialysis.

Turbid acellular peritoneal fluid of a non-infectious aetiology is an uncommon entity in peritoneal dialysis and is characterised by a high concentration of triglycerides in the peritoneal fluid. The most common causes include cancer, lymphatic obstructions, pancreatitis, trauma, and even the use of certain medications such as calcium antagonists. The largest studies concerning this entity have been carried out in patients of Asian descent. We recently diagnosed 4 cases of turbid acellular peritoneal fluid at our institution in relation to the use of calcium antagonists. We reviewed the primary characteristics of these cases and examined the relationship between the use of calcium antagonists and triglyceride levels in the peritoneal fluid of stable patients on peritoneal dialysis during 2010. Of the four patients with turbid acellular peritoneal fluid, 75% were male and 75% were on treatment with manidipine; in all cases, the issue was resolved by suspending medication. Mean triglyceride levels were 314 mg/dl. Mean triglyceride levels in 36 stable patients on peritoneal dialysis were 8.1mg/dl, with a range of 1-35 mg/dl. Mean triglyceride levels in patients with and without calcium antagonist treatment were very similar, at 7.81 mg/dl and 8.6 mg/dl, respectively. We did not observe significant differences in terms of the type of calcium antagonist prescribed. In our experience, we believe that calcium antagonists should be considered as a cause of turbid acellular peritoneal fluid in patients on peritoneal dialysis, in particular manidipine. We do not find it useful to determine triglyceride levels in the peritoneal fluid of asymptomatic patients on treatment with calcium antagonists.

Relación entre la presión intrabdominal en diálisis peritoneal con las hernias y fugas / The link between intra-abdominal pressure in peritoneal dialysis and hernias and fugues

La presión intrabdominal normal es igual a la atmosférica (cero). En Diálisis Peritoneal con la introducción del líquido intraperitoneal, la presión intrabdominal aumenta. En varios estudios se aconseja que esta no supere los 16-20 cm. H2O. Además de las posibles molestias abdominales, una presión intrabdominal elevada puede tener relación con los problemas de la pared abdominal, como hernias y fugas y tener implicaciones en el transporte peritoneal y el déficit de ultrafiltración. Los objetivos del presente trabajo fueron: conocer los niveles de presión intrabdominal de los enfermos prevalentes en diálisis peritoneal, valorar los factores que influyen en llos valores de esta presión y estudiar retrospectivamente la relación entre presión intrabdominal y desarrollo de hernias y fugas. Realizamos un estudio transversal, observacional y retrospectivo de valoración de la presión intrabdominal en los enfermos prevalentes, estables, con más de tres meses en diálisis peritoneal. La presión intrabdominal se midió mediante el método descrito por Durand: paciente en decúbito supino, con el volumen peritoneal diurno. La presión intrabdominal final es la media entre las mediciones realizadas durante la inspiración y la espiración, se expresa en cm. de H2O, y se especifica el volumen drenado. También se realizó una medida en sedestación y en bipedestación. Se estudiaron 34 pacientes, 66% varones, edad media de 61.2±14 años, 3 con poliquistosis renal, un índice de comorbilidad de Charlson medio de 7,9, un índice de masa corporal medio de 27.4±4.2 y un tiempo medio en DP de 21±12 meses. El volumen medio diurno fue de 1796±385 mL y el nocturno de 2100±254 mL. Un 32% de los pacientes tenían antecedentes de cirugía abdominal y un 5% de hernias, reparadas antes del inicio de la diálisis peritoneal. La media de presión intrabdominal en decúbito fue de 17.5±4.1 cm. de H2O, y un volumen medio por superficie corporal de 1141±253 ml/m2. Un 23.5 % tenían una presión intrabdominal mayor a 20 cm. de H2O. En sedestación la media fue de 28±5.5 cm. de H2O y en bipedestación de 43.7±5.3 cm. de H2O. Los enfermos con presión intrabdominal > 20 cm. H2O tenían más porcentaje de hernias (50% vs 12 %) y fugas pericatéter (37 % vs. 12 %). Como principales conclusiones, podemos destacar que los niveles de presión intrabdominal de nuestros pacientes son algo más elevados que en otras series. A mayor edad, mayor comorbilidad y mayor índice de masa corporal, la presión intrabdominal es más elevada. Los enfermos con presión intrabdominal elevada presentaron más episodios de hernias y fugas (AU)

Normal intra-abdominal pressure is equal to atmospheric pressure (zero). In peritoneal dialysis the introduction of intra-peritoneal liquid increases intra-abdominal pressure. In various studies it is recommended that this does not exceed 16-20cm H2O. In addition to possible abdominal discomfort, high intra-abdominal pressure can be linked to problems with the abdominal wall, such as hernias and fugues, and have implications for peritoneal transport and ultrafiltration deficit. The aims of this study were the following: to find out the intra-abdominal pressure levels in the prevalent type of patients in peritoneal dialysis, to assess the factors influencing the values for this pressure and to study the relationship between intra-abdominal pressure and the development of hernias and fugues, retrospectively. A transversal, observational and retrospective study was conducted to measure intra-abdominal pressure in the prevalent, stable patients who had been on peritoneal dialysis for more than three months. Intra-abdominal pressure was measured using the method described by Durand: patient in a supine position, with diurnal peritoneal volume. The final intra-abdominal pressure is the average of the measurements taken during inspiration and expiration, is expressed in cm H2O and the volume drained is specified. Measurements were also taken in sitting and standing positions. 34 patients were studied, 66% of them male, with an average age of 61.2±14 years, 3 with polycystic kidney disease, an average Charlson comorbidity index of 7.9, an average body mass index of 27.4±4.2 and an average of 21±12 months on PD. Average diurnal volume was 1796±385 mL and nocturnal 2100±254 mL. 32% of the patients had a history of abdominal surgery and 5% of hernias, remedied before the start of peritoneal dialysis. The average intra-abdominal pressure lying down was 17.5±4.1cm H2O, with an average volume by body surface of 1141±253ml/m2. 23.5 % had an intra-abdominal pressure of over 20cm H2O. In a sitting position the average was 28±5.5cm H2O and standing up it was 43.7±5.3cm H2O. Patients with an intra-abdominal pressure of > 20cm H2O had a higher percentage of hernias (50% vs 12%) and pericatheter fugues (37% vs. 12%). As the principal conclusions, we would stress that the intra-abdominal pressure levels in our patients were rather higher than in other series. The greater the age, comorbidity and major body mass index, the higher the intra-abdominal pressure. Patients with high intra-abdominal pressure have more episodes of hernias and fugues (AU)

Aplicabilidad clínica de dos índices pronósticos de mortalidad precoz en pacientes añosos incidentes en hemodiálisis: escaso acierto predictivo en el paciente individual / Two prognostic scores for early mortality and their clinical applicability in elderly patients on haemodialysis: poor predictive success in individual patients

Introducción: Existen pocos estudios sobre el pronóstico individual del paciente añoso que inicia hemodiálisis (HD) crónica, pese a que frecuentemente se plantea el dilema entre el posible beneficio y la carga que supone el propio tratamiento. Objetivos: Evaluar la utilidad del índice pronóstico del Registro REIN (REIN) y del modelo predictivo de mortalidad precoz del Registre de Malalts Renals de Catalunya (RMRC) en pacientes añosos incidentes en HD al compararlos con la supervivencia observada. Métodos: Se estudiaron los pacientes mayores de 75 años que iniciaron y siguieron HD en nuestro Servicio entre 2004-2009. Se recogieron variables sociodemográficas, clínicas, comorbilidad, mortalidad y si el inicio de HD fue planificado o no. Se calculó el índice REIN y la probabilidad de mortalidad precoz del RMRC. Resultados: Se analizaron 63 pacientes de una edad media de 80,4 ± 3,9 años, con un número de enfermedades añadidas de 3,4 ± 1,8. Un 59% iniciaron HD por un catéter, un 57,1% tenían enfermedad cardiovascular, el 15,9% neoplasia, el 31,2% enfermedad pulmonar obstructiva crónica y el 19% nefropatía diabética. La supervivencia observada a los 6 y a los 12 meses fue de 79,4 y 73%, respectivamente. Los pacientes que no se valían por sí mismos (21%) presentaban una mayor mortalidad a los 6 meses. El análisis de las curvas ROC (Receiver Operating Characteristic) mostró una escasa concordancia entre la mortalidad observada y los índices REIN (área 0,681, p = 0,046) y RMRC (área 0,594, p = 0,255). Conclusiones: El índice de probabilidad de mortalidad al año del RMRC es poco útil en la práctica clínica para el pronóstico individual. El índice REIN es sólo ligeramente concordante con la mortalidad observada en los primeros 6 meses de HD. Una pobre autonomía funcional fue el principal factor de riesgo de mortalidad precoz en los pacientes añosos que inician HD (AU)

Introduction: Few studies address the individual prognosis of an elderly patient beginning chronic haemodialysis (HD), despite the fact that doctors must frequently weigh the possible benefits and disadvantages of prescribing this treatment. Objectives: Evaluate the usefulness of the REIN Registry’s prognosis score and the predictive index for early mortality proposed by the Catalan Registry of Renal Patients (RMRC, Registre de Malalts Renals de Catalunya) in elderly patients beginning HD by comparing indices with observed survival rates. Methods: We studied patients aged 75 years and older who started and continued HD treatment in our Department between 2004 and 2009. Socio-demographic, clinical, co-morbidity and mortality data were recorded, in addition to whether or not initiating HD was planned. We calculated the REIN score and the RMRC probability of early mortality. Results: We analysed 63 patients with a mean age of 80.4±3.9 years and a mean of 3.4±1.8 additional illnesses. Of these patients, 59% began HD with a catheter; 57.1% had cardiovascular disease, 15.9% neoplasia, 31.2% chronic obstructive pulmonary disease and 19% diabetic nephropathy. Survival rates observed at 6 and at 12 months were 79.4% and 73%, respectively. Patients who began HD on an emergency basis (47.7%) or who were unable to care for themselves (21%) had higher 6-month mortality rates. Analysis of ROC curves (Receiver Operating Characteristic) showed slight concordance between the observed mortality rates and both the REIN score (area 0.681, P=.046) and the RMRC index (area 0.594, P=.255). Conclusions: The RMRC 1-year mortality probability model is not well adapted for individual prognoses in clinical practice. The REIN score only shows slight concordance with the mortality rates observed in the first 6 months of HD. Poor functional independence was the main risk factor for early mortality in elderly patients begining HD treatment

Two prognostic scores for early mortality and their clinical applicability in elderly patients on haemodialysis: poor predictive success in individual patients.

INTRODUCTION: Few studies address the individual prognosis of an elderly patient beginning chronic haemodialysis (HD), despite the fact that doctors must frequently weigh the possible benefits and disadvantages of prescribing this treatment. OBJECTIVES: Evaluate the usefulness of the REIN Registry's prognosis score and the predictive index for early mortality proposed by the Catalan Registry of Renal Patients (RMRC, Registre de Malalts Renals de Catalunya) in elderly patients beginning HD by comparing indices with observed survival rates. METHODS: We studied patients aged 75 years and older who started and continued HD treatment in our Department between 2004 and 2009. Socio-demographic, clinical, co-morbidity and mortality data were recorded, in addition to whether or not initiating HD was planned. We calculated the REIN score and the RMRC probability of early mortality. RESULTS: We analysed 63 patients with a mean age of 80.4 +/- 3.9 years and a mean of 3.4 +/- 1.8 additional illnesses. Of these patients, 59% began HD with a catheter; 57.1% had cardiovascular disease, 15.9% neoplasia, 31.2% chronic obstructive pulmonary disease and 19% diabetic nephropathy. Survival rates observed at 6 and at 12 months were 79.4% and 73%, respectively. Patients who began HD on an emergency basis (47.7%) or who were unable to care for themselves (21%) had higher 6-month mortality rates. Analysis of ROC curves (Receiver Operating Characteristic) showed slight concordance between the observed mortality rates and both the REIN score (area 0.681, P=.046) and the RMRC index (area 0.594, P=.255). CONCLUSIONS: The RMRC 1-year mortality probability model is not well adapted for individual prognoses in clinical practice. The REIN score only shows slight concordance with the mortality rates observed in the first 6 months of HD. Poor functional independence was the main risk factor for early mortality in elderly patients beginning HD treatment.