ISPD Cardiovascular and Metabolic Guidelines in Adult Peritoneal Dialysis Patients Part II - Management of Various Cardiovascular Complications

Association between beta-blocker utilization and heart failure mortality in the peritoneal dialysis population: a cohort study

Background

The prognostic significance of beta(β)-blocker therapy in patients at end-stage renal disease, specifically those receiving peritoneal dialysis (PD) and presenting with heart failure, remains inadequately elucidated due to limited research conducted thus far.

Methods

A retrospective analysis was performed on a cohort comprising 608 patients receiving PD between September 2007 and March 2019, with a subsequent follow-up period extending until December 2020. Cox regression and propensity score matching weighted analysis was used to model adjusted hazard ratios for β-blocker use with heart failure-related mortality. Competing risk analysis and subgroup analysis were carried out to further elucidate the correlation.

Results

β-blockers were prescribed for 56.1% of the peritoneal dialysis patients. Heart failure occurred in 43.4% of the total population and 15.5% of deaths were due to heart failure. The prescription of β-blockers was associated with a 43% lower adjusted hazard ratio (HR) for heart failure death within the cohort (95% confidence interval [CI] = 0.36-0.89; P = 0.013). Even after accounting for competing risk events, patients in the group using β-blockers demonstrated a significantly lower cumulative risk of heart failure-related mortality compared to those not using β-blockers (P = 0.007). This protective effect of β-blockers was also observed in subgroup analyses. Conversely, β-blocker use had no statistically significant associations with all-cause mortality.

Conclusion

The use of β-blockers was associated with a reduced risk of heart failure-related mortality in the PD population. Future randomized clinical trials are warranted to confirm the beneficial effect of β-blockers in the context of PD.

Delivering Personalized, Goal-Directed Care to Older Patients Receiving Peritoneal Dialysis

Background

An aging population living with chronic kidney disease and progressing to kidney failure, subsequently receiving peritoneal dialysis (PD) is growing. A significant proportion of these patients are also living with multi-morbidities and some degree of frailty. Recent practice recommendations from the International Society of Peritoneal Dialysis advocate for high-quality, goal-directed PD prescription, and the Standardized Outcomes of Nephrology-PD initiative emphasized the need for an individualized, goal-based care approach in all patients receiving PD treatment. In older patients, this approach to PD care is even more important. A frailty screening assessment, followed by a comprehensive geriatric assessment (CGA) prior to PD initiation and when dictated by change in relevant circumstances is paramount in tailoring PD care and prescription according to the needs, life goals, as well as clinical status of older patients with kidney failure.

Summary

Our review aimed to summarize the different dimensions to be taken into account when delivering PD care to the older patient - from frailty screening and CGA in older patients receiving PD to employing a personalized, goal-directed PD prescription strategy, to preserving residual kidney function, optimizing blood pressure (BP) control, and managing anemia, to addressing symptom burden, to managing nutritional intake and promoting physical exercise, and to explore telehealth opportunities for the older PD population.

Key Messages

What matters most to older PD patients may not be simply extending survival, but more importantly, to be living comfortably on PD treatment with minimal symptom burden in a home environment and to minimize treatment complications.

Triglyceride glucose-body mass index and cardiovascular mortality in patients undergoing peritoneal dialysis: a retrospective cohort study

BACKGROUND

Recent studies have shown that triglyceride glucose-body mass index (TyG-BMI) is associated with the risk of ischemic stroke and coronary artery disease. However, little attention has been given to the association between TyG-BMI and cardiovascular disease (CVD) mortality in patients undergoing peritoneal dialysis (PD). Therefore, this study aimed to explore the relationship between TyG-BMI and CVD mortality in southern Chinese patients undergoing PD.

METHODS

Incident patients receiving PD from January 1, 2006, to December 31, 2018, with baseline serum triglyceride, glucose, and body mass index (BMI) information, were recruited for this single-center retrospective cohort study. TyG-BMI was calculated based on fasting plasma glucose, triglyceride, and BMI values. The association between TyG-BMI, CVD and all-cause mortality was evaluated using a multivariate-adjusted Cox proportional hazard regression model.

RESULTS

Of 2,335 patients, the mean age was 46.1 ± 14.8 years; 1,382 (59.2%) were male, and 564 (24.2%) had diabetes. The median TyG-BMI was 183.7 (165.5-209.2). Multivariate linear regression showed that advanced age, male sex, history of CVD, higher levels of albumin and low-density lipoprotein cholesterol, and higher urine output were correlated with a higher TyG-BMI (P < 0.05). During a median follow-up period of 46.6 (22.4-78.0) months, 615 patients died, of whom 297 (48.2%) died as a result of CVD. After adjusting for demographics and comorbidities, TyG-BMI was significantly associated with an increased risk of CVD mortality (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.05-2.17) and all-cause mortality (HR 1.36, 95% CI 1.05-1.75). After full adjustment, the 28% risk of CVD mortality (HR 1.28, 95% CI 1.13-1.45) and 19% risk of all-cause mortality were elevated (HR 1.19, 95% CI 1.09-1.31) when TyG-BMI increased by 1 stand deviation (SD) (34.2).

CONCLUSIONS

A higher baseline TyG-BMI was independently associated with an increased risk of CVD and all-cause mortality in patients receiving PD.

Current Insights into Cellular Determinants of Peritoneal Fibrosis in Peritoneal Dialysis: A Narrative Review

Peritoneal fibrosis is the final process of progressive changes in the peritoneal membrane due to chronic inflammation and infection. It is one of the main causes of discontinuation of peritoneal dialysis (PD), apart from peritonitis and cardiovascular complications. Over time, morphological changes occur in the peritoneal membranes of patients who use PD. Of those are mesothelial-to-mesenchymal transition (MMT), neoangiogenesis, sub-mesothelial fibrosis, and hyalinizing vasculopathy. Several key molecules are involved in the complex pathophysiology of peritoneal fibrosis, including advanced glycosylation end products (AGEs), transforming growth factor beta (TGF-β), and vascular endothelial growth factor (VEGF). This narrative review will first discuss the physiology of the peritoneum and PD. Next, the multifaceted pathophysiology of peritoneal fibrosis, including the effects of hyperglycemia and diabetes mellitus on the peritoneal membrane, and the promising biomarkers of peritoneal fibrosis will be reviewed. Finally, the current and future management of peritoneal fibrosis will be discussed, including the potential benefits of new-generation glucose-lowering medications to prevent or slow down the progression of peritoneal fibrosis.

Novel Aspects of the Immune Response Involved in the Peritoneal Damage in Chronic Kidney Disease Patients under Dialysis

Chronic kidney disease (CKD) incidence is growing worldwide, with a significant percentage of CKD patients reaching end-stage renal disease (ESRD) and requiring kidney replacement therapies (KRT). Peritoneal dialysis (PD) is a convenient KRT presenting benefices as home therapy. In PD patients, the peritoneum is chronically exposed to PD fluids containing supraphysiologic concentrations of glucose or other osmotic agents, leading to the activation of cellular and molecular processes of damage, including inflammation and fibrosis. Importantly, peritonitis episodes enhance peritoneum inflammation status and accelerate peritoneal injury. Here, we review the role of immune cells in the damage of the peritoneal membrane (PM) by repeated exposure to PD fluids during KRT as well as by bacterial or viral infections. We also discuss the anti-inflammatory properties of current clinical treatments of CKD patients in KRT and their potential effect on preserving PM integrity. Finally, given the current importance of coronavirus disease 2019 (COVID-19) disease, we also analyze here the implications of this disease in CKD and KRT.

The relationship between platelet distribution width and new-onset cardiovascular disease events in patients with peritoneal dialysis

Objectives

The global mortality rate from chronic kidney disease (CKD) has increased over the past two decades. Typically, peritoneal dialysis (PD) remains a useful alternative treatment for end-stage renal disease. Cardiovascular disease (CVD) is the main complication in PD patients. In terms of prognosis, it is reported that platelet distribution width (PDW) can predict adverse CVD events. However, the relationship between PDW and new-onset CVD in PD patients is not clear. This study aimed to explore the relationship between PDW and new-onset CVD in PD patients.

Methods

This was a retrospective cohort study, from 4 July 2005 to 31 December 2019, and a total of 1557 patients were recruited. PDW was respectively categorized into two groups: PDW ≤13.2 fL and PDW >13.2 fL. The primary outcome was a new-onset CVD event. Cox proportional hazards models were performed to assess the hazard ratio (HR). Receiver-operating characteristic (ROC) curves were applied to evaluate the predictive accuracy of the PDW on CVD events.

Results

During follow-up, 114 new-onset CVD events were recorded. Cox proportional hazards models showed a higher risk of CVD events in patients with high PDW (HR = 1.862 95%CI 1.205–2.877, p = 0.005). Kaplan–Meier cumulative incidence curves showed the risk of the first occurrence of CVD events was greater in the high PDW group (p = 0.006).

Conclusions

High PDW is associated with new-onset cardiovascular disease events in PD patients.

A Case of Hepatitis E Virus Infection: One of Differential Diagnosis of Liver Injury in Patients Undergoing Peritoneal Dialysis

Background

There are numerous causes of liver function disorder in patients undergoing peritoneal dialysis (PD). Infection with the Hepatitis E virus (HEV) is a rare cause of liver injury, and the behavior of HEV in patients with PD is unclear. Since patients undergoing dialysis are frequently polypharmatic, liver injury caused by HEV infection may be misdiagnosed as drug-induced liver injury.

Case Presentation

A 61-year-old woman with PD developed abrupt elevation of blood transaminase levels on a routine outpatient session. Since the patient has been receiving tolvaptan as the only new medication, we suspected tolvaptan induced liver injury. In further investigating the cause of liver injury, the blood screening test was found to be positive for HEV-IgA. The patient was diagnosed with HEV infection, and had a self-limited course.

Conclusion

When encountered with patients developing liver injury during PD, HEV infection should be included in the differential diagnosis.

Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.

Multifrequency bioimpedance by spectroscopy vs. routine methods in the management of hydration status in peritoneal dialysis patients: A randomized control trial

Background

Overhydration (OH) is common in peritoneal dialysis (PD) and increases the cardiovascular risk. Multifrequency bioimpedance spectroscopy (BIS) has been proposed to estimate the hydration in dialysis. Our objective was to evaluate if BIS is superior than control based on clinical assessment plus single-frequency bioimpedance (SF-BIA) on the fluid control and intermediate cardiovascular outcomes.

Methods

Randomized controlled study in adult PD patients, with a 9-month follow-up, allocated into two groups: control and BIS. Data were collected from medical records. SF-BIA and BIS, laboratory exams, ambulatory blood pressure monitoring, echocardiography (ECHO), and pulse wave velocity (PWV) were evaluated. The BIS data were available to the medical team only in BIS group.

Results

34 patients completed the study, 17 in each group. At the endpoint the BIS group had a significant (p < 0.05) greater proportion of patients with OH/extracellular water (OH/ECW%) ≤ 15% than the control (94.1% vs. 52.9%), and a lower OH mean (2.1 ± 1.6 vs. 0.9 ± 1.1 L). The control group has a significant increase in the tumor necrosis factor alpha median concentration from baseline to six [11.9 (6.0–24.1) vs. 44.7 (9.4–70.6) pg/ml] and 9 months [11.9 (6.0–24.1) vs. 39.4 (27.9–62.6) pg/ml], and in the N-terminal fragment of pro-B-type natriuretic peptide median [239 (171.5–360.5) vs. 356 (219–1,555) pg/ml]. For cardiovascular parameters, BIS group presented a significant reduction in radial PWV [7.7 (6.9–9.2) vs. 6.5 (5.5–8.4) m/s] at 9 month, while in the control presented a significant increase in mean central systolic blood pressure (BP) (106.8 ± 11.2 vs. 117.6 ± 16.5 mmHg) and in central diastolic BP (90.4 ± 9.8 vs. 103.3 ± 12.5 mmHg) at 9 months. The left ventricular mass (LVM)/body surface presented a significant reduction in the control (109.6 ± 30.8 vs. 101.2 ± 28.9 g/m²) and BIS group (107.7 ± 24.9 vs. 96.1 ± 27.0 g/m²) at 9 months.

Conclusion

The results suggest BIS is superior than the clinical evaluation plus SF-BIA for the fluid control of PD patients.

Clinical trial registration

[https://www.ClinicalTrials.gov], identifier [RBR-10k8j3bx].

Causes and risk factors for peritoneal dialysis withdrawal

INTRODUCTION

This study intends to investigate the causes and risk factors for withdrawal from peritoneal dialysis (PD) in patients with ESRD.

METHODS

293 patients admitted to the peritoneal dialysis center in nephrology department for PD treatment were divided into 175 cases in group A (continuous treatment group) and 118 cases in group B (withdrawal group).

RESULTS

The proportion of patients in group B whose primary disease was glomerulonephritis was significantly lower than that in group A (P<0.05), whereas the proportion of patients with diabetic nephropathy was significantly higher in group B than in group A (P<0.05). Group A received better emotional support and care services from family members than group B. Family care was mostly severely impaired in patients who died and were lost to follow-up.

CONCLUSION

Diabetes mellitus, level of knowledge regarding PD, depression and family care are risk factors for withdrawal from PD. This article is protected by copyright. All rights reserved.

Évaluation de la performance de la mesure conventionnelle et séquentielle de la pression artérielle en centre chez les patients en dialyse péritonéale à Dakar

Introduction : L’objectif de cette étude était d’évaluer les performances des mesures conventionnelles (MCPA) et séquentielles (MSPA) de la pression artérielle en prenant la MAPA comme référence. Patients et méthodes : A travers une étude transversale incluant 17 patients suivis dans l’unité de DP de l’Hôpital Aristide Le Dantec, la PA a été mesurée par 3 méthodes : i) une mesure automatisée (OMRON M3 COMFORT) effectué par un personnel de santé dite MCPA (OMRON M3 COMFORTTM) ; ii) la moyenne de 5 mesures automatisées chez un patient isolé dans un box dite MSPA ; iii) la MAPA des 24h avec l’appareil CONTECTM (Germany). L’HTA a été retenue devant une PA supérieure à 130/80 mmHg à la MAPA des 24h. Résultats : L’aire sous la courbe (AUC) de la PAS était similaire (p=0,28) entre la MSPA [AUC, 0,933 ; IC à 95 %, 0,813 – 1,000] et la MCPA [AUC, 0,900 ; IC à 95 %, 0,752 – 1,000]. Concernant la PAD, la MSPA [AUC, 0,858 ; IC à 95 %, 0,638 – 1,000] était similaire (p=1) à la MCPA [AUC, 0,917 ; IC à 95 %, 0,753 – 1,000]. À l’analyse de Bland-Altman, la MCPA surestimait  la PAS de 11,65 mmHg et la PAD de 3,94 mmHg. La MSPA quant à elle surestimait la PAS de 6,2 mmHg et la PAD de 4,35 mmHg. Conclusion : La MSPA et la MCPA sont performantes dans le diagnostic de l’HTA ambulatoire chez les patients en dialyse péritonéale à Dakar.

Therapeutic Hypothermia Reduces Peritoneal Dialysis Induced Myocardial Blood Flow Heterogeneity and Arrhythmia

Background: Moderate therapeutic hypothermia (TH) is a well-recognized cardio-protective strategy. The instillation of fluid into the peritoneum provides an opportunity to deliver moderate hypothermia as primary prevention against cardiovascular events. We aimed to to investigate both cardiac perfusion consequences (overall blood flow and detailed assessment of perfusion heterogeneity) and subsequently simulate the associated arrhythmic risk for patients undergoing peritoneal dialysis (PD) induced TH. Methods: Patients underwent high resolution myocardial perfusion scanning using high resolution 256 slice CT scanning, at rest and with adenosine stress. The first visit using the patient's usual PD regimen, on the second visit the same regime was utilized but with cooled peritoneal dialysate at 32°C. Myocardial blood flow (MBF) was quantified from generated perfusion maps, reconstructed in 3D. MBF heterogeneity was assessed by fractal dimension (FD) measurement on the 3D left ventricular reconstruction. Arrhythmogenicity was quantified from a sophisticated computational simulation using a multi-scale human 3D ventricle wedge electrophysiological computational model. Results: We studied 7 PD patients, mean age of 60 ± 7 and mean vintage dialysis of 23.6 ± 17.6 months. There were no significant different in overall segmental MBF between normothermic condition (NT) and TH. MBF heterogeneity was significantly decreased (-14%, p = 0.03) at rest and after stress (-14%, p = 0.03) when cooling was applied. Computational simulation showed that TH allowed a normalization of action potential, QT duration and T wave. Conclusion: TH-PD results in moderate hypothermia leading to a reduction in perfusion heterogeneity and simulated risk of non-terminating malignant ventricular arrhythmias.

Association of blood pressure after peritoneal dialysis initiation with the decline rate of residual kidney function in newly-initiated peritoneal dialysis patients

Background

Lower blood pressure (BP) levels are linked to a slower decline of kidney function in patients with chronic kidney disease (CKD) without kidney replacement therapy. However, there are limited data on this relation in peritoneal dialysis (PD) patients. Here we evaluated the association of BP levels with the decline of residual kidney function (RKF) in a retrospective cohort study.

Methods

We enrolled 228 patients whose PD was initiated between 1998 and 2014. RKF was measured as the average of creatinine and urea clearance in 24-hr urine collections. We calculated the annual decline rate of RKF by determining the regression line for individual patients. RKF is thought to decline exponentially, and thus we also calculated the annual decline rate of logarithmic scale of RKF (log RKF). We categorized the patients’ BP levels at 3 months after PD initiation (BP_3M) into four groups (Optimal, Normal & High normal, Grade 1 hypertension, Grade 2 & 3 hypertension) according to the 2018 European Society of Cardiology and European Society of Hypertension Guidelines for the management of arterial hypertension.

Results

The unadjusted, age- and sex-adjusted, and multivariable-adjusted decline rate of RKF and log RKF decreased significantly with higher BP_3M levels (P for trend <0.01). Compared to those of the Optimal group, the multivariable-adjusted odds ratios (95% confidence interval) for the faster side of the median decline rate of RKF and log RKF were 4.04 (1.24–13.2) and 5.50 (1.58–19.2) in the Grade 2 and 3 hypertension group, respectively (p<0.05).

Conclusions

Higher BP levels after PD initiation are associated with a faster decline in RKF among PD patients.

Effectiveness of a continuous interactive communication system for home care nursing assistance of peritoneal dialysis

Background

The Japanese population is aging quickly. New methods of supporting peritoneal dialysis (PD) for elderly patients are essential if we are to increase the number of such patients.

Methods

We established a two-way communication system between a central hospital and stations for visiting nurses. Home care nurses provided physicians at the central hospital with clinical findings for patients undergoing assisted PD. We compared 11 patients undergoing PD assisted by home care nurses in continuous interactive communication with the central hospital (cases) with 11 patients undergoing unassisted PD who were matched by sex, primary disease, estimated glomerular filtration rate at the start of PD, and age at the start of PD (controls). The variables compared were hospitalization due to heart failure, exit-site infection, peritonitis, and the composite of these causes during a 1-year period. In addition, we compared patient clinical factors between groups.

Results

Although differences in the number of hospitalizations attributable to exit-site infection, peritonitis, and heart failure were not significant, the difference in the number of hospitalizations attributable to a composite of these causes was significant. Exit-site scores were significantly better in the case group than in the control group.

Conclusions

PD assisted by home care nurses using an established continuous interactive communication system was associated with significantly better exit-site scores. Fewer cases than controls were hospitalized.

Risk Factors for Early Peritoneal Dialysis Discontinuation: Importance of Heart Failure

BACKGROUND

The number of patients on peritoneal dialysis (PD) in our hospital has increased during the past 5 years, but the number discontinuing PD has also increased. The purpose of this study was to identify the risk factors for PD discontinuation by analyzing the association between technical survival period (defined as the duration of PD) and various clinical factors.

METHODS

We retrospectively investigated 87 patients who were started on PD at our hospital and attended regularly from April 2015 to March 2020, and we analyzed the association between technical survival period and various clinical factors. We also looked for associations between technical survival period and hospitalizations for heart failure, peritonitis, and exit-site infections among patients undergoing PD.

RESULTS

The patients using renin-angiotensin-aldosterone system inhibitors (RASi) (P = 0.0218), those with left ventricular ejection fraction (LVEF) > 50% (P = 0.0194) when they started PD, and those with estimated glomerular filtration rate (eGFR) ≥ 6 (mL/ min/1.73m²) (P = 0.0013) at the initiation of PD showed significantly longer technical survival period, and those who were hospitalized for heart failure had significantly shorter period (P = 0.0008).

CONCLUSION

Treatment of RASi, LVEF > 50% and eGFR ≥ 6 mL/ min/1.73m² when the initiation of PD and better volume control to prevent ultrafiltration failure and heart failure may improve technical survival period in patients undergoing PD.

盐摄入量对腹膜透析大鼠残余肾功能的影响

OBJECTIVE

To assess the effect of salt intake on residual renal function in rats and explore the possible mechanism.

OBJECTIVE

SD rats were 5/6-nephrectomized to induce chronic renal failure followed by peritoneal dialysis for 4 weeks (n=18) or without dialysis treatment (control group; n=18). In both groups, the rats were divided into 3 subgroups and were given lowsalt diet (0.02% NaCl), normal salt diet (0.4% NaCl), and high-salt diet (4% NaCl). After 8 and 12weeks, blood pressure and creatinine and sodium levels in the blood, urine, and peritoneal dialysate of the rats were examined. Glomerular sclerosis, tubulointerstitial fibrosis, and protein expression levels of RAS components (ACE-1, AGT, and AT-1) in renal cortical tissue of the rats were evaluated.

OBJECTIVE

The residual renal function of the rats all decreased especially in rats with high salt intake for 8and 12 weeks. In peritoneal dialysis group, the rats with high-salt diet showed signficiantly increased renal interstitial fibrosis score (P=0.036), glomerular sclerosis index (P=0.045), systolic blood pressure (P=0.004), diastolic blood pressure (P=0.048), and renal expressions of AGT, ACE-1, and AT1 (P < 0.05) as compared with those with normal salt intake. In the rats fed the same high-salt diet, the renal interstitial fibrosis score, glomerular sclerosis index, diastolic blood pressure increase, and renal AGT and ACE-1 expression levels were significantly lower in the peritoneal dialysis group than in the control group (P < 0.05). A positive correlation was noted between the reduction of residual renal function and sodium intake in the rats.

OBJECTIVE

In rats with chronic renal failure, high salt intake promotes the activation of the renal RAS system, increases blood pressure, and agrevates renal fibrosis to accelerate the decline of residual renal function, and peritoneal dialysis partially reduces the damage of residual renal function induced by high-salt diets by removing excessive sodium.

The calcium concentration of peritoneal dialysis solution modifies levels of key mediators of peritoneal fibrosis

BACKGROUND

To explore the effects of different calcium concentrations of peritoneal dialysis solution (PDS) on continuous ambulatory peritoneal dialysis (CAPD) and expression of vimentin (VIM), fibroblast-specific protein (FSP1), and E-cadherin.

MATERIALS AND METHODS

This was a pilot study (#ChiCTR1900021387) conducted from January 2017 to December 2019 at the Hospital. The patients were randomized to undergo CAPD using PDS with a calcium concentration of 1.25 mmol/L (low concentration group) or 1.75 mmol/L (high concentration group). Changes in biochemistry before dialysis and at 6 and 12 months were analyzed.

RESULTS

There were 50 and 52 participants in the low and high calcium groups. The blood biochemical indexes were all different between the two groups (all Ptime  < .05, Pgroup  < .05, Pinteraction  < .05), but they remained within their normal ranges. VIM and FSP1 increased over 12 months (Ptime  < .05); VIM and FSP1 levels in the high concentration group were higher than in the low concentration group (Pgroup  < .05, Pinteraction  < .05), while E-cadherin showed the inverse association (Ptime  < .001, Pgroup  < .001, Pinteraction  < .001). There was no difference in complications (P = .973).

CONCLUSION

The calcium concentration in PDS might be an important factor affecting the progression of peritoneal fibrosis.

Development of a framework for minimum and optimal safety and quality standards for hemodialysis and peritoneal dialysis

Substantial heterogeneity in practice patterns around the world has resulted in wide variations in the quality and type of dialysis care delivered. This is particularly so in countries without universal standards of care and governmental (or other organizational) oversight. Most high-income countries have developed such oversight based on documentation of adherence to standardized, evidence-based guidelines. Many low- and lower-middle-income countries have no or only limited organized oversight systems to ensure that care is safe and effective. The implementation and oversight of basic standards of care requires sufficient infrastructure and appropriate workforce and financial resources to support the basic levels of care and safety practices. It is important to understand how these standards then can be reasonably adapted and applied in low- and lower-middle-income countries.

Association between Peritoneal Glucose Exposure and Peritonitis in Peritoneal Dialysis Patients: TheBalANZ Trial

Background

Glucose is the primary osmotic medium used in most peritoneal dialysis (PD) solutions, and exposure to glucose has been shown to exert detrimental effects both locally, at the peritoneal membrane, and systemically. Moreover, high dialysate glucose exposure may predispose patients to an increased risk of peritonitis, perhaps as a result of impaired host defences, vascular disease, and damage to the peritoneal membrane.

Methods

In this post-hoc analysis of a multicenter, multinational, open-label randomized controlled trial of neutral pH, low-glucose degradation product (GDP) versus conventional PD solutions ( balANZ trial), the relationship between peritonitis rates of low (< 123.1 g/day) versus high (≥ 123.1 g/day) dialysate glucose exposure was evaluated in 177 incident PD patients over a 2-year study period.

Results

Peritonitis rates were 0.44 episodes per patient-year in the low-glucose exposure group and 0.31 episodes per patient-year in the high-glucose exposure group, (incidence rate ratio [IRR] 0.69, p = 0.09). There was no significant association between dialysate glucose exposure and peritonitis-free survival on univariable analysis (high glucose exposure hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.40 –1.08) or on multivariable analysis (adjusted HR 0.64, 95% CI 0.39 – 1.05). Moreover, there was no relationship between peritoneal glucose exposure and type of organism causing peritonitis. Physician-rated severity of first peritonitis episodes was similar between groups, as was rate and duration of hospital admission.

Conclusions

Overall, this study did not identify an association between peritoneal dialysate glucose exposure and peritonitis occurrence, severity, hospitalization, or outcomes. A further large-scale, prospective, randomized controlled trial evaluating patient-level outcomes is merited.

Geriatric nutritional risk index is associated with mortality in peritoneal dialysis patients

BACKGROUND

Malnutrition is one of the most common complications among dialysis patients. The Geriatric Nutritional Risk Index (GNRI) is rarely used in dialysis patients, especially peritoneal dialysis (PD).

AIM

To use the GNRI to evaluate the initial nutritional state of PD patients and to examine the association between the GNRI and mortality in chronic PD patients.

METHODS

We retrospectively examined the medical records at our centre to identify all adults (≥18 years) who had undergone PD for over 3 months before recruitment from January 2005 to December 2017. The correlation between the GNRI and mortality was examined by Kaplan-Meier and Cox proportional hazards analyses.

RESULTS

A total of 1804 patients was enrolled in the study. Significant correlations were noted between the initial GNRI and Charlson index, uric acid, blood calcium, potassium, triglycerides, low-density lipoprotein cholesterol, haemoglobin and so on. Multivariate Cox proportional hazards analyses demonstrated that the GNRI was associated with all-cause mortality (hazard ratio = 0.96, P < 0.001, 95% confidence interval: 0.95-0.98) after adjustment. Compared with the lowest GNRI group, all-cause mortality decreased significantly for each level of GNRI after adjusting for various influencing factors, and the mortality risk of the highest GNRI grade decreased by 66%. The Kaplan-Meier analysis survival rate was significantly different among the four groups in terms of all-cause mortality and cardiovascular and cerebrovascular mortality (log-rank test, P < 0.05).

CONCLUSIONS

These results demonstrated that the GNRI is significantly associated with mortality and can be a simple, clinically useful marker for the assessment of nutritional status in PD patients.

Clinic and Home Blood Pressure Monitoring for the Detection of Ambulatory Hypertension Among Patients on Peritoneal Dialysis

The International Society of Peritoneal Dialysis recommends that adequate blood pressure (BP) assessment among patients on peritoneal dialysis should at least include measurements performed once-weekly at home and at each visit at clinic. However, the quality of evidence to support this guidance is suboptimal. Using ambulatory daytime BP as reference standard, we explored the diagnostic performance of clinic and home BP recordings in a cohort of 81 stable patients receiving peritoneal dialysis. BP was recorded using 3 different methodologies: (1) triplicate automated clinic BP recordings after a 5-minute seated rest with the validated monitor HEM 705 CP (Omron Healthcare); (2) 1-week averaged home BP recorded with a validated automated monitor on awaking and at bedtime; and (3) ambulatory BP monitoring with the Mobil-O-Graph device (IEM, Germany). The area under the curve of receiver operating characteristic curves in detection of ambulatory daytime systolic BP (SBP) ≥135 mm Hg was similar for clinic [area under the curve, 0.859; 95% CI, 0.776-0.941] and home SBP (area under the curve, 0.895; 95% CI, 0.815-0.976). In Bland-Altman analysis, clinic SBP overestimated daytime ambulatory SBP by 5.02 mm Hg with 95% limits of agreement ranging from -17.92 to 27.96 mm Hg. Similarly, home SBP overestimated daytime ambulatory SBP by 4.23 mm Hg, again with wide 95% limits of agreement (-16.05 to 24.51 mm Hg). These results show that 1-week averaged home SBP is of at least similar accuracy with standardized clinic SBP in diagnosing hypertension confirmed by ambulatory BP monitoring among patients on peritoneal dialysis.

Long-term effects on PTH and mineral metabolism of 1.25 versus 1.75 mmol/L dialysate calcium in peritoneal dialysis patients: a meta-analysis

Background

This study aimed to compare 1.25 and 1.75 mmol/L dialysate calcium for their effects on parathyroid hormone (PTH) and mineral metabolism in peritoneal dialysis (PD).

Methods

The PubMed, Cochrane Library, and EmBase databases were searched from inception to October 2016. Methodological quality assessment of the included studies was performed using the risk of bias tool of the Review Manager software. The meta-analysis was carried out with the Stata12.0 software. Subgroup analysis was performed by study design [randomized controlled trial (RCT) and non-RCT]. Odds ratios or standardized mean differences were used to assess the outcome measures, including intact parathyroid hormone (i-PTH) levels, serum total calcium amounts, ionized calcium levels, phosphate concentrations, and peritonitis episodes.

Results

Seven studies were enrolled in the synthesized analysis, including 4 RCTs and 3 non-RCTs. All studies compared 1.25 mmol/L and 1.75 mmol/L dialysate calcium for PD. Pooled analysis revealed that 1.75 mmol/L dialysate calcium significantly reduced i-PTH levels compared with the 1.25 mmol/L dose in PD patients. However, 1.25 mmol/L dialysate calcium was superior to the 1.75 mmol/L dose in decreasing the levels of serum total calcium and ionized calcium in PD patients. No significant differences in phosphate amounts and peritonitis episodes were observed between the two groups.

Conclusion

These findings indicated that 1.75 mmol/L dialysate calcium is more appropriate for PD patients with secondary hyperparathyroidism. Meanwhile, 1.25 mmol/L dialysate calcium is more favorable to PD patients with secondary hypercalcemia. However, further well-designed and high-quality studies are required to validate these findings.

Changes in Outcomes over Time Among Incident Peritoneal Dialysis Patients in Southern China

Background:The present study was to investigate the changes in outcomes of incident patients who started peritoneal dialysis (PD) between 2006 - 2010 and 2011 - 2015 in Southern China.Methods:In this single-center cohort study, incident PD patients from January 1, 2006, to December 31, 2015, were enrolled. Collected data included baseline demographic, clinical, biochemical characteristics, and outcomes. Patients who initiated PD during 2006 - 2010 and 2011 - 2015 were followed up until December 31, 2011, and December 31, 2016, respectively. Peritonitis rate, patient survival, and technique survival were compared between the 2 incident cohorts.Results:A total of 2,021 incident PD patients were enrolled, with a mean age of 47.2 ± 15.2 years, 40.6% female. Compared with the 2006 - 2010 cohort (n = 1,073), patients initiating PD during 2011 - 2015 (n = 948) were younger (46.2 ± 14.8 vs 48.1 ± 15.5 years, p = 0.006), had similar baseline estimate glomerular filtration rate (eGFR) (5.81 ± 2.41 vs 5.81 ± 2.89 mL/min/1.73 m², p = 0.109) and comparable percentage of diabetes mellitus (24.9% vs 25.7%, p = 0.682). The overall peritonitis rate in the 2011 - 2015 cohort was lower than in the 2006 - 2010 cohort (0.158 vs 0.161 episodes per year, p = 0.001). At the end of 1, 3, and 5 years, the 2006 - 2010 and 2011 - 2015 cohorts had patient survival rates of 94%, 82%, 64%, and 97%, 87%, 74%, respectively (p < 0.001). After multivariable adjustment, patients starting PD in 2011 - 2015 were associated with lower risk of all-cause mortality (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.60 - 0.98). In gender and age-stratified models, male patients had a significantly lower risk of all-cause mortality (HR 0.58, 95% CI 0.41 - 0.83), and patients with age < 65 years showed a significantly lower risk of cardiovascular (CV) mortality (HR 0.63, 95% CI 0.40 - 0.99) in 2011 - 2015 compared with 2006 - 2010. The death-censored technique survival rates were not significantly different between the 2 cohorts (p = 0.234).Conclusion:Peritonitis rates and patient survival on PD continue to improve. Patients initiating PD between 2011 and 2015 were associated with better outcomes.

Assessment and Management of Hypertension among Patients on Peritoneal Dialysis

Approximately 7%-10% of patients with ESKD worldwide undergo peritoneal dialysis (PD) as kidney replacement therapy. The continuous nature of this dialytic modality and the absence of acute shifts in pressure and volume parameters is an important differentiation between PD and in-center hemodialysis. However, the burden of hypertension and prognostic association of BP with mortality follow comparable patterns in both modalities. Although management of hypertension uses similar therapeutic principles, long-term preservation of residual diuresis and longevity of peritoneal membrane function require particular attention in the prescription of the appropriate dialysis regimen among those on PD. Dietary sodium restriction, appropriate use of icodextrin, and limited exposure of peritoneal membrane to bioincompatible solutions, as well as adaptation of the PD regimen to the peritoneal transport characteristics, are first-line therapeutic strategies to achieve adequate volume control with a potential long-term benefit on technique survival. Antihypertensive drug therapy is a second-line therapeutic approach, used when BP remains unresponsive to the above volume management strategies. In this article, we review the available evidence on epidemiology, diagnosis, and treatment of hypertension among patients on PD and discuss similarities and differences between PD and in-center hemodialysis. We conclude with a call for randomized trials aiming to elucidate several areas of uncertainty in management of hypertension in the PD population.

Prognostic value of inflammation-based prognostic scores on outcome in patients undergoing continuous ambulatory peritoneal dialysis

BACKGROUND

Inflammation-based prognostic scores have been used as outcome predictors in patients with cancer or on hemodialysis. However, their role in patients on continuous ambulatory peritoneal dialysis (CAPD) remains unclear. This study aimed to examine the prognostic value of inflammation-based composite scores for mortality in CAPD patients.

METHODS

This study was conducted in CAPD patients enrolled from January 1, 2006 to December 31, 2014 and followed until December 31, 2016. Three inflammation-based prognostic scores, including Glasgow prognostic score (GPS), prognostic nutritional index (PNI), and prognostic index (PI), were conducted in this study. The associations between these scores and all-cause or cardiovascular mortality were evaluated by Kaplan-Meier method and Cox proportional hazards models. The areas under the curve (AUC) of receiver-operating characteristic (ROC) analysis were used to determine the predictive values of mortality.

RESULTS

A total of 1501 patients were included. During a median follow-up of 38.7 (range, 21.6-62.3) months, 346 (23.1%) patients died, of which 168 (48.6%) were due to cardiovascular diseases (CVD). After adjustment for confounders, the results showed that elevated GPS, PNI, and PI scores were all independently associated with all-cause [GPS: Score 1: hazard ratio(HR) 3.94, 95% confidence interval(CI) 2.90-5.35; Score 2: HR 7.56, 95% CI 5.35-10.67; PNI: HR 1.82, 95% CI 1.36-2.43; PI: Score 1: HR 2.08, 95% CI 1.63-2.65; Score 2: HR 3.03, 95% CI 2.00-4.60)] and CVD mortality(GPS: Score 1: HR 4.41, 95% CI 2.76-7.03; Score 2: HR 9.64, 95% CI 5.72-16.26; PNI: HR 1.63, 95% CI 1.06-2.51; PI: Score 1: HR 2.57, 95% CI 1.81-3.66, Score 2: HR 3.85, 95% CI 1.99-7.46).The AUC values of GPS score were 0.798 (95% CI0.770-0.826) for all-cause mortality and 0.781 (95% CI 0.744-0.817) for CVD mortality, both of which significantly higher than those of PNI and PI scores (P < 0.001, respectively).

CONCLUSIONS

All elevated GPS, PNI, and PI scores were independently associated with all-cause and CVD mortality. The GPS score showed better predictive value than PNI and PI scores in CAPD patients.

Associations Between Peritoneal Glucose Exposure, Glucose Degradation Product Exposure, and Peritoneal Membrane Transport Characteristics in Peritoneal Dialysis Patients: Secondary Analysis of the balANZ Trial

BACKGROUND

Glucose is the most commonly used osmotic medium in peritoneal dialysis (PD) solutions, and its use has been associated with both local and systemic adverse effects. Previous, single-center, observational cohort studies have reported conflicting findings regarding whether a relationship exists between peritoneal glucose exposure and peritoneal small solute transport rate.

METHODS

In this secondary analysis of the balANZ multicenter, multinational, randomized controlled trial of a neutral pH, ultra-low glucose degradation product (biocompatible) versus conventional PD solutions over a 2-year period, the relationship between time varying peritoneal glucose exposure and change in peritoneal solute transport rate, (measured as dialysate to plasma creatinine ratio at 4 hours [D:PCr_4h]), was evaluated using multivariable, multilevel linear regression. Baseline peritoneal glucose exposure was also assessed as either a continuous or categorical variable.

RESULTS

The study included 165 patients (age 58.1 ± 14.2 years, 55% male, 33% diabetic). Peritoneal glucose exposure increased over time (coefficient 1.49, 95% confidence interval [CI] 1.07 - 1.92 and was not significantly associated with change in D:PCr_4h (coefficient 0.00004, 95% CI -0.0001 - 0.0002, p = 0.68). Similar results were found when peritoneal glucose exposure was examined as a baseline continuous or categorical variable. A significant 2-way interaction was observed with PD solution type, whereby a progressive increase in D:PCr_4h was seen in the patients receiving conventional PD solution, but not in those receiving biocompatible solution.

CONCLUSIONS

Increases in peritoneal solute transport rate in PD patients over time were not associated with peritoneal glucose exposure, although a strong and positive association with PD solution glucose degradation product content was identified. Peritoneal glucose exposure may be a less important consideration than peritoneal glucose degradation product exposure with respect to peritoneal membrane function over time.

Temporal Trends and Factors Associated with Medication Prescription Patterns in Peritoneal Dialysis Patients

INTRODUCTION

Patients on peritoneal dialysis (PD) suffer from a high burden of comorbidities, which are managed with multiple medications. Determinants of prescription patterns are largely unknown in this population. This study assesses temporal changes and factors associated with medication prescription in a nationally representative population of patients on PD under the universal coverage healthcare system in Brazil.

METHODS

Incident patients recruited in the Brazilian Peritoneal Dialysis Study (BRAZPD) from December 2004 to January 2011, stratified by prior hemodialysis (HD) treatment, were included in the analysis. Multivariable logistic regression was used to assess the association between medication prescription and socioeconomic factors. Yearly prevalent cross-sections were calculated to estimate prescription over time.

RESULTS

Medication prescription was in general higher among patients who had previously received HD, compared with those who started renal replacement therapy (RRT) directly on PD. Prescription increased from baseline to 6 months of PD therapy, particularly in those who did not previously receive HD. After accounting for patient characteristics, significant associations were found between socioeconomic factors, geographic region, and medication prescription patterns. Finally, the prescription of all cardioprotective and anemia medications and phosphate binders increased significantly over time.

CONCLUSION

In a PD population under universal coverage in a developing country, there was an increase in drug prescription during the first 6 months on PD, and a trend toward more liberal prescription of medications in later years. Independent from patient characteristics and comorbidities, socioeconomic factors influenced drug prescriptions that likely impact patient outcome, calling for public health action to decrease potential inequities in management of comorbidities in PD patients.

Repeated Bioimpedance Measurements Predict Prognosis of Peritoneal Dialysis Patients

BACKGROUND

Fluid overload is a major risk factor for mortality in patients undergoing peritoneal dialysis (PD). However, few studies have investigated the effect of chronic exposure to sustained fluid overload on long-term outcomes.

METHOD

A total of 284 prevalent PD patients were included in this prospective study. Repeated multifrequency body composition analysis was performed 12 months apart, and 1-year cumulative chronic fluid overload were used to predict all-cause mortality and the risk for transfer to hemodialysis (HD) during the ensuing 15.6 ± 9.1 months.

RESULTS

The prevalence of fluid overload was approximately 27%. Interestingly, a substantial number of hypervolemic patients at first test were persistently hypervolemic at their second test. With this, chronic fluid overload was observed in 18.3% (n = 52). Notably, most of chronic fluid overload patients had diabetes (86.5%), and it was accompanied by concomitant changes in peritoneal membrane characteristics, a higher progression rate to high transporter. The risk of transfer to HD increased 2.8 times in patients with chronic fluid overload than in those without. Also, it significantly increased the risk of mortality (p = 0.038). Surprisingly, subgroup analysis found that patients with euvolemic status at follow-up experienced no mortality despite being in a fluid overload state at baseline.

CONCLUSIONS

One-year chronic exposure to fluid overload is a strong independent risk factor for transfer to HD and death in prevalent PD patients. Although the fluid status of most PD patients is not easily changed over time, becoming euvolemic during the entire PD treatment period seems to be very important.

Abdominal Aortic Calcifications Predict Survival in Peritoneal Dialysis Patients

BACKGROUND

Peripheral arterial disease and vascular calcifications contribute significantly to the outcome of dialysis patients. The aim of this study was to evaluate the prognostic role of severity of abdominal aortic calcifications and peripheral arterial disease on outcome of peritoneal dialysis (PD) patients using methods easily available in everyday clinical practice.

METHODS

We enrolled 249 PD patients (mean age 61 years, 67% male) in this prospective, observational, multicenter study from 2009 to 2013. The abdominal aortic calcification score (AACS) was assessed using lateral lumbar X ray, and the ankle-brachial index (ABI) using a Doppler device.

RESULTS

The median AACS was 11 (range 0 - 24). In 58% of the patients, all 4 segments of the abdominal aorta showed deposits, while 19% of patients had no visible deposits (AACS 0). Ankle-brachial index was normal in 49%, low (< 0.9) in 17%, and high (> 1.3) in 34% of patients. Altogether 91 patients (37%) died during the median follow-up of 46 months. Only 2 patients (5%) with AACS 0 died compared with 50% of the patients with AACS ≥ 7 (p < 0.001). The adjusted hazard ratio for all-cause mortality was 4.85 (95% confidence interval [CI] 1.94 - 24.46) for aortic calcification (AACS ≥ 7), 2.14 for diabetes (yes/no), 0.93 for albumin (per 1 g/L), and 1.04 for age (per year). A low or high ABI were not independently associated with mortality.

CONCLUSIONS

Severe aortic calcification was a strong predictor of all-cause mortality in PD patients. The evaluation of aortic calcifications by lateral X ray is a simple method that allows the identification of high-risk patients.

Low GDP Solution and Glucose-Sparing Strategies for Peritoneal Dialysis

Long-term exposure to a high glucose concentration in conventional peritoneal dialysis (PD) solution has a number of direct and indirect (via glucose degradation products [GDP]) detrimental effects on the peritoneal membrane, as well as systemic metabolism. Glucose- or GDP-sparing strategies often are hypothesized to confer clinical benefits to PD patients. Icodextrin (glucose polymer) solution improves peritoneal ultrafiltration and reduces the risk of fluid overload, but these beneficial effects are probably the result of better fluid removal rather than being glucose sparing. Although frequently used for glucose sparing, the role of amino acid-based solution in this regard has not been tested thoroughly. When glucose-free solutions are used in a combination regimen, published studies showed that glycemic control was improved significantly in diabetic PD patients, and there probably are beneficial effects on peritoneal function. However, the long-term effects of glucose-free solutions, used either alone or as a combination regimen, require further studies. On the other hand, neutral pH-low GDP fluids have been shown convincingly to preserve residual renal function and urine volume. The cost effectiveness of these solutions supports the regular use of neutral pH-low GDP solutions. Nevertheless, further studies are required to determine whether neutral pH-low GDP solutions exert beneficial effects on patient-level outcomes, such as peritonitis, technique survival, and patient survival.

Peritoneal dialysis practice in Australia and New Zealand: A call to sustain the action

This paper updates a previous 'Call to Action' paper (Nephrology 2011; 16: 19-29) that reviewed key outcome data for Australian and New Zealand peritoneal dialysis patients and made recommendations to improve care. Since its publication, peritonitis rates have improved significantly, although they have plateaued more recently. Peritoneal dialysis patient and technique survival in Australian and New Zealand have also improved, with a reduction in the proportion of technique failures attributed to 'social reasons'. Despite these improvements, technique survival rates overall remain lower than in many other parts of the world. This update includes additional practical recommendations based on published evidence and emerging initiatives to further improve outcomes.

Low prognostic nutritional index associated with cardiovascular disease mortality in incident peritoneal dialysis patients

PURPOSE

The prognostic nutritional index (PNI), a variable based on serum albumin concentration and total lymphocyte count in peripheral blood, is reported as a predictor of mortality in a variety of malignant tumor population. This study is aimed to evaluate whether PNI has prognostic value in patients on peritoneal dialysis (PD).

METHODS

This was a single-center, retrospective observational cohort study conducted in incident PD patients from January 1, 2006 to June 30, 2014, and followed until June 30, 2015. The associations of PNI levels with mortality were evaluated by Kaplan-Meier method and Cox proportional hazards models.

RESULTS

A total of 345 patients were included in this study. Median PNI level at baseline was 40.7 (range: 18.8-75.5) for all patients. During follow-up, 59 (17.1%) died during follow-up, among which 31 (52.5%) were due to cardiovascular diseases (CVD). In crude analysis, the patients with low PNI had a significant increase risk of CVD and all-cause mortality [hazard ratio (HR) 3.07, 95% confidence interval (CI) 1.51-6.25 and HR 2.18, 95% CI 1.28-3.72, respectively)]. After adjusting age, Davies comorbidity score, hemoglobin and leukocytes, the patients with low PNI still had a significant increased risk of CVD mortality (HR 2.37, 95% CI 1.10-5.12). However, there was no significant difference in risk of all-cause mortality (HR 1.72, 95% CI 0.97-3.06).

CONCLUSIONS

Low PNI at initiation of PD was independently associated with an increased CVD mortality.

Platelet index levels and cardiovascular mortality in incident peritoneal dialysis patients: a cohort study

Prior studies have shown that the levels of some platelet (PLT) indices were associated with mortality in patients undergoing hemodialysis. We aimed to investigate whether the changes in PLT indices associated with mortality in patients on peritoneal dialysis (PD). A single-center, retrospective observational cohort study was conducted in incident PD patients from 1 January 2006 to 31 December 2012, and followed up until 31 December 2014. Cox proportional hazard models were used to examine the relationships between the levels of PLT indices including PLT, plateletcrit (PCT), mean platelet volume (MPV), platelet distribution width (PDW), platelet large cell ratio (PLCR), and mortality. Of 1324 patients, 276 (20.8%) died during follow-up (median, 37; IQR, 3-107.4 months), among which 134 were due to cardiovascular diseases (CVD). The highest tertile of PLT levels at baseline was associated with increased risk for cardiovascular mortality after adjustment for demographic, clinical characteristics, and laboratory variables (hazard ratio [HR]:1.93; 95% confidence interval [CI]: 1.16-3.20). The similar treads were also observed in the middle and the highest tertile of the PCT level (HR: 1.68, 95%CI: 1.00-2.81 and HR: 1.89, 95%CI: 1.14-3.14, respectively). In addition, the highest tertile of PCT was associated with increased all-cause mortality (HR: 1.41, 95%CI: 1.01-1.96). However, none of the associations in MPV, PDW, and PLCR analyses reached statistical significance (HR: 0.71, 95%CI: 0.43-1.16; HR: 0.72, 95%CI: 0.45-1.18 and HR: 0.74, 95%CI: 0.46-1.19, respectively). These results suggest that higher PLT and PCT may be associated with higher risk for cardiovascular mortality in incident PD patients. Additional studies are needed to investigate whether correction of these two PLT indices reduces the risk.

The Current State of Peritoneal Dialysis

Technical innovations in peritoneal dialysis (PD), now used widely for the long-term treatment of ESRD, have significantly reduced therapy-related complications, allowing patients to be maintained on PD for longer periods. Indeed, the survival rate for patients treated with PD is now equivalent to that with in-center hemodialysis. In parallel, changes in public policy have spurred an unprecedented expansion in the use of PD in many parts of the world. Meanwhile, our improved understanding of the molecular mechanisms involved in solute and water transport across the peritoneum and of the pathobiology of structural and functional changes in the peritoneum with long-term PD has provided new targets for improving efficiency and for intervention. As with hemodialysis, almost half of all deaths on PD occur because of cardiovascular events, and there is great interest in identifying modality-specific factors contributing to these events. Notably, tremendous progress has been made in developing interventions that substantially reduce the risk of PD-related peritonitis. Yet the gains have been unequal among individual centers, primarily because of unequal clinical application of knowledge gained from research. The work to date has further highlighted the areas in need of innovation as we continue to strive to improve the health and outcomes of patients treated with PD.

Efficacy and safety of warfarin in dialysis patients with atrial fibrillation: a systematic review and meta-analysis

Objective

To systematically review and meta-analyse the risk–benefit ratio of warfarin users compared with non-warfarin users in patients with atrial fibrillation (AF), who are undergoing dialysis.

Methods

We searched PubMed/MEDLINE, EMBASE, SCOPUS, Web of Science, Cochrane Library, grey literature, conference proceedings, trial registrations and also did handsearch. Cohort studies without language restrictions were included. Two investigators independently conducted a full abstraction of data, risk of bias and graded evidence. Effect estimates were pooled using random-effect models.

Main outcome measure

All-cause mortality, total stroke/thromboembolism and bleeding complications.

Results

14 studies included 37 349 dialysis patients with AF, of whom 12 529 (33.5%) were warfarin users. For all-cause mortality: adjusted HR=0.99 (95% CI 0.89 to 1.10; p=0.825), unadjusted risk ratio (RR)=1.00 (95% CI 0.96 to 1.04; p=0.847). For stroke/thromboembolism: adjusted HR=1.06 (95% CI 0.82 to 1.36; p=0.676), unadjusted incidence rate ratio (IRR)=1.23 (95% CI 0.94 to 1.61; p=0.133). For ischaemic stroke/transient ischaemic attack, adjusted HR=0.91 (95% CI 0.57 to 1.45; p=0.698), unadjusted IRR=1.16 (95% CI 0.84 to 1.62; p=0.370). For haemorrhagic stroke, adjusted HR=1.60 (95% CI 0.91 to 2.81; p=0.100), unadjusted IRR=1.48 (95% CI 0.92 to 2.36; p=0.102). Major bleeding was increased among warfarin users; adjusted HR=1.35 (95% CI 1.11 to 1.64; p=0.003) and unadjusted IRR=1.22 (95% CI 1.07 to 1.40; p=0.003).

Conclusions

Among dialysis patients with AF, warfarin therapy was not associated with mortality and stroke/thromboembolism, but significantly increased the risk of major bleeding. More rigorous studies are essential to demonstrate the effect of warfarin for stroke prophylaxis in dialysis patients with AF.

Serum Magnesium Levels and Hospitalization and Mortality in Incident Peritoneal Dialysis Patients: A Cohort Study

BACKGROUND

Prior studies have shown the association of low serum magnesium levels with adverse health outcomes in patients undergoing hemodialysis. There is a paucity of such studies in patients undergoing peritoneal dialysis (PD).

STUDY DESIGN

Cohort study.

SETTING & PARTICIPANTS

10,692 patients treated with PD from January 1, 2007, through December 31, 2011, in facilities operated by a single large dialysis organization in the United States.

PREDICTOR

Baseline serum magnesium levels, examined as 5 categories (<1.8, 1.8-<2.0, 2.0-<2.2 [reference], 2.2-<2.4, and ≥2.4mg/dL).

OUTCOMES

Time to first hospitalization and time to death using competing-risks regression models.

RESULTS

The distribution of baseline serum magnesium levels in the cohort was <1.8mg/dL, 1,928 (18%); 1.8 to <2.0mg/dL, 2,204 (21%); 2.0 to <2.2mg/dL, 2,765 (26%); 2.2 to <2.4mg/dL, 1,765 (16%); and ≥2.4mg/dL, 2,030 (19%). Of 10,692 patients, 6,465 (60%) were hospitalized at least once and 1,392 (13%) died during follow-up (median, 13; IQR, 7-23 months). Baseline serum magnesium level < 1.8mg/dL was associated with higher risk for hospitalization and all-cause mortality after adjustment for demographic and clinical characteristics (adjusted HRs of 1.23 [95% CI, 1.14-1.33] and 1.21 [95% CI, 1.03-1.42], respectively). The higher risk for hospitalization persisted upon adjustment for laboratory variables, whereas that for all-cause mortality was attenuated to a nonsignificant level. The greatest risk for hospitalization was in patients with low serum albumin levels (<3.5g/dL; P for interaction < 0.001).

LIMITATIONS

Possibility of residual confounding by unmeasured variables cannot be excluded.

CONCLUSIONS

Lower serum magnesium levels may be associated with higher risk for hospitalization in incident PD patients, particularly those with hypoalbuminemia. Additional studies are needed to confirm these findings and investigate whether correction of hypomagnesemia reduces these risks.