Glycosylated hemoglobin and albumin-corrected fructosamine are good indicators for glycemic control in peritoneal dialysis patients.

PURPOSE: Diabetes mellitus (DM) is the most common cause of end-stage renal disease and is an important risk factor for morbidity and mortality after dialysis. However, glycemic control among such patients is difficult to assess. The present study examined glycemic control parameters and observed glucose variation after refilling different kinds of fresh dialysate in peritoneal dialysis (PD) patients. METHODS: A total of 25 DM PD patients were recruited, and continuous glucose monitoring system (CGMS) was applied to measure interstitial fluid (ISF) glucose levels at 5-min intervals for 3 days. Patients filled out diet and PD fluid exchange diaries. The records measured with CGMS were analyzed and correlated with other glycemic control parameters such as fructosamine, albumin-corrected fructosamine (AlbF), glycosylated hemoglobin (HbA1c), and glycated albumin levels. RESULTS: There were significant correlations between mean ISF glucose and fructosamine (r = 0.45, P<0.05), AlbF (r = 0.54, P<0.01), and HbA1c (r = 0.51, P<0.01). The ISF glucose levels in glucose-containing dialysate increased from approximately 7-8 mg/dL within 1 hour of exchange in contrast to icodextrin dialysate which kept ISF glucose levels unchanged. CONCLUSION: HbA1c and AlbF significantly correlated with the mean ISF glucose levels, indicating that they are reliable indices of glycemic control in DM PD patients. Icodextrin dialysate seems to have a favorable glycemic control effect when compared to the other glucose-containing dialysates.

Associations of metabolic syndrome and its components with cardiovascular outcomes among non-diabetic patients undergoing maintenance peritoneal dialysis.

BACKGROUND: Metabolic syndrome (MS) is thought to be a risk marker for cardiovascular diseases in the general population and in patients with chronic kidney disease. This study investigated whether the presence of MS also modifies cardiovascular (CV) outcomes among non-diabetic patients undergoing long-term peritoneal dialysis (PD). METHODS: We enrolled 280 patients from a medical centre in North Taiwan who began PD between January 1999 and December 2005 and followed them until December 2009. MS was defined by the modified National Cholesterol Educational Programme (Adult Treatment Panel III) criteria. All parameters and biochemical data were collected by chart review. Patient outcomes (overall and CV death, fatal or non-fatal CV events) were recorded during the follow-up period. Survival was analysed by the Kaplan-Meier method, and the influence of MS and its components on outcomes were analysed by Cox regression models. RESULTS: The average follow-up period was 49.2 months. Non-diabetic patients with MS had worse outcomes than those without MS or at risk for MS, but better than their diabetic counterparts. By multivariate analysis, MS was independently associated with increased risk for CV death (hazard ratio, HR = 13.27) and fatal or non-fatal CV events (HR = 10.50). Among five MS components, hypertriglyceridaemia, low high-density lipoprotein levels and hyperglycaemia were significant risk factors for adverse CV outcomes. CONCLUSIONS: MS is a potent risk marker for adverse CV outcomes in non-diabetic patients on PD. Timely interventions targeting specific component of this syndrome may be required in this subset of patients.

Intraperitoneal vascular endothelial growth factor C level is related to peritoneal dialysis ultrafiltration.

BACKGROUND: Local inflammation and neovascularization have a negative influence on peritoneal dialysis (PD). Patients with higher peritoneal transport have higher interleukin-6 (IL-6) and vascular endothelial growth factor-A (VEGF-A) levels in their dialysate. However, the relationship of other members of the VEGF family, such as VEGF-C, to peritoneal transport or ultrafiltration (UF) is yet to be studied. METHODS: Peritoneal cytokine and growth factor levels were determined during the peritoneal equilibration test (PET). Ultrafiltration, peritoneal clearance and residual renal function were also considered. RESULTS: Forty-two PD patients were enrolled. They had been on PD for at least 1 month and free of peritonitis for at least 1 month prior to the study. Patients with high or high average PET had higher dialysate IL-6 and VEGF-C. Dialysate IL-6 and VEGF-C correlated negatively with PET and UF. CONCLUSIONS: Dialysate VEGF-C is related to higher transport rate and poorer UF. The role of VEGF-C in PD deserves further study.

Rate of decline of residual renal function is associated with all-cause mortality and technique failure in patients on long-term peritoneal dialysis.

BACKGROUND: Residual renal function (RRF) at the initiation of peritoneal dialysis (PD) therapy can predict patient outcome. However, RRF declines with time at variable rates in different patients. This study was performed to compare the impact of baseline RRF and the rate of RRF decline on patient survival and on death-censored technique survival after initiation of long-term PD. METHODS: We enrolled 270 patients with sufficient urine amount (daily urine volume >100 mL) from a medical centre in North Taiwan who began PD between January 1996 and December 2005 and followed them until December 2007. The study population was stratified by the decline rate of RRF into a fast, intermediate and slow decline group. The Kaplan-Meier survival analysis was used to determine patient survival and technique survival. The Cox regression model was used to identify factors associated with patient outcome. The proportional odds polychotomous logistic regression model was used to identify variables associated with rapid decline of RRF. RESULTS: During an average follow-up period of 45 months, 50 (18.5%) deaths, 67 (24.8%) death-censored technique failures (transfer to haemodialysis) and 43 (15.9%) renal transplantations occurred. The median rate of RRF decline was 0.885 mL/min/1.73 m(2) per year. Survival analysis showed that patients with fast RRF decline had worse survival and increased risk of technique failure. The multivariate Cox regression model confirmed that the rate of RRF decline was an independent factor associated with patient and technique survival and was a more powerful prognostic factor than basal RRF. Variables associated with a rapid decline of RRF were larger body mass index, presence of diabetes, prior history of congestive heart failure, use of diuretics, peritonitis episodes and hypotensive events. CONCLUSIONS: Our data indicate that the rate of decline of RRF is a more powerful prognostic factor than baseline RRF associated with all-cause mortality and technique failure in patients on long-term PD. To prevent accelerated loss of RRF, it is imperative that every effort be made to avoid overdiuresis, peritonitis and hypotensive episodes, especially in those with diabetes, obesity and congestive heart failure.

Predictors of faster decline of residual renal function in Taiwanese peritoneal dialysis patients.

OBJECTIVE: Loss of residual renal function (RRF) in peritoneal dialysis (PD) patients is a powerful predictor of mortality. The present study was conducted to determine the predictors of faster decline of RRF in PD patients in Taiwan. METHODS: The study enrolled 270 patients starting PD between January 1996 and December 2005 in a single hospital in Taiwan. We calculated RRF as the mean of the sum of 24-hour urea and creatinine clearance. The slope of the decline of residual glomerular filtration rate (GFR) was the main outcome measure. Data on demographic, clinical, laboratory, and treatment parameters; episodes of peritonitis; and hypotensive events were analyzed by Student t-test, Mann-Whitney U-test, and chi-square, as appropriate. All variables with statistical significance were included in a multivariate linear regression model to select the best predictors (p < 0.05) for faster decline of residual GFR. RESULTS: All patients commencing PD during the study period were followed for 39.4 +/- 24.0 months (median: 35.5 months). The average annual rate of decline of residual GFR was 1.377 +/- 1.47 mL/min/m(2). On multivariate analysis, presence of diabetes mellitus (p < 0.001), higher baseline residual GFR (p < 0.001), hypotensive events (p = 0.001), use of diuretics (p = 0.002), and episodes of peritonitis (p = 0.043) independently predicted faster decline of residual GFR. Male sex, old age, larger body mass index, and presence of coronary artery disease or congestive heart failure were also risk factors on univariate analysis. CONCLUSIONS: Our results suggested that diabetes mellitus, higher baseline residual GFR, hypotensive events, and use of diuretics are independently associated with faster decline of residual GFR in PD patients in Taiwan.

[A project to reduce waiting time during peritoneal dialysis visits].

This study aimed to reduce the length of waiting time for patients undergoing peritoneal dialysis (PD). Long waiting times and over-crowding in the waiting area were two of the most frequent complaints among PD patients at a peritoneal dialysis center. The center carried out a survey to investigate patients' satisfaction with their visit and the length of time they had to wait during their visit. The average waiting time was 88.3 minutes, and the average score for satisfaction was 78. After a Cause-and-Effect diagram analysis, recommendations to improve patient visits were as follows: (1) establish a computerized appointment system, (2) provide designated arrival times, (3) reorganize visit procedures, (4) integrate the pre-visit preparation process, and (5) rearrange the waiting areas. With better processes, patients might obtain thorough evaluations and nursing care while waiting. Two months after the implementation of these proposals, the average waiting time had shortened to 27.4 minutes, and scores for satisfaction had increased to 86, showing the proposed measures to be highly effective.

Early initiation of dialysis and late implantation of catheters adversely affect outcomes of patients on chronic peritoneal dialysis.

OBJECTIVES: Predialysis nephrology care is thought to affect morbidity and mortality in hemodialysis patients. This study evaluated the impact of different patterns of predialysis care on outcomes of patients undergoing chronic peritoneal dialysis (PD). DESIGN: Retrospective cohort. SETTING AND PARTICIPANTS: 275 patients enrolled from January 1997 to March 2005 in a medical center in North Taiwan who recently initiated dialysis were classified according to early or late referral to nephrologists (> or =6 or <6 months of dialysis), planned or late implantation of Tenckhoff catheters (absence or presence of preceding emergent hemodialysis), and early or late start of dialysis [glomerular filtration rate (GFR) > or =5 or <5 mL/minute/1.73 m(2)]. MAIN OUTCOME MEASURES: All-cause mortality and hospitalization. RESULTS: During a median follow-up of 2.5 years, 41 deaths, 38 transfers to hemodialysis, and 26 renal transplantations occurred. Late start of dialysis was associated with a significant survival benefit (log rank, p = 0.012) and, along with planned implantation of catheters, exhibited a reduced risk for all-cause hospitalization (log rank, p = 0.025, 0.013). The predictors of overall mortality included baseline GFR [hazard ratio (HR) 1.18, p = 0.023], age (HR 1.07, p < 0.001), and diabetes (HR 3.64, p = 0.001); whereas the risk factors for all-cause hospitalization included age (HR 1.02, p = 0.012), late implantation of catheters (HR 1.78, p = 0.011), and diabetes (HR 1.92, p = 0.005). The timing of nephrology referral did not affect either death or hospitalization. CONCLUSIONS: Our data do not support earlier initiation of PD, but underscore the importance of planned implantation of catheters before commencement of chronic PD.

Sexual dysfunction in peritoneal dialysis patients.

BACKGROUND/AIMS: Sexual dysfunction in patients undergoing peritoneal dialysis (PD) is highly prevalent, but studies addressing this issue are scarce. This cross-sectional study aims to evaluate sexual dysfunction and the determinants among PD patients. METHODS: All chronic PD patients in 8 PD centers were asked to complete a self-reported questionnaire - the International Index of Erectile Function (IIEF) for men and the Index of Female Sexual Function (IFSF) for women - so that sexual function could be assessed. They also answered the Beck Depression Inventory (BDI) to measure depressive symptoms. RESULTS: Among 294 patients invited for study, 54 men (mean age 48.8 +/- 10.8 years) and 45 women (mean age 43.6 +/- 7.4 years) were willing to and completed the sexual function questionnaires. The median IIEF score in the men was 56.25. The prevalence of erectile dysfunction, identified by the score in erectile domain of IIEF