Peritoneal Protein Loss With Time in Peritoneal Dialysis

Longitudinal evolution of peritoneal protein loss (PPL), a reflection of hydrostatic pressure-driven leak of plasma proteins through the large-pore pathway, is not clear. Time on PD causes loss of mesothelial cells, vasculopathy, and increased thickness of the submesothelial fibrous layer. Are these structural changes associated with progressive increase of PPL, in a parallel with the rise in the D/P creatinine? The aim of the present study was to identify longitudinal changes of PPL over time. This single-center, longitudinal study included 52 peritoneal dialysis (PD) patients with a median follow-up of 26.5 months, evaluated at two different time points with a minimum interval of 6 months. Repeated measures analysis was performed using paired sample t-test or the nonparametric Wilcoxon signed-rank test, depending on the distribution. After a median interval of 15.5 months, lower levels of residual renal function and urine volume, lower Kt/V, and creatinine clearance were found. D/P creatinine and PPL were stable, but a decrease in ultrafiltration was present. Systemic inflammation, nutrition, and volume overload showed no significant change with time on PD. Analysis of a subpopulation with over 48 months between initial and subsequential assessment (n = 11) showed again no difference in inflammation, nutritional and hydration parameters from baseline, but importantly PPL decreased after more than 4 years on PD (mean difference 1.2 g/24, p = 0.033). D/P creatinine and dip of sodium remained unchanged. The absence of deleterious effects of time on PD is reassuring, pointing to the benefit of updated PD prescription, including the standard use of more biocompatible solutions towards membrane preservation and adjusted prescription avoiding overhydration and inflammation while maintaining nutritional status. After controlling for confounders, PPL may act as a biomarker of acquired venous vasculopathy, even if small pore fluid transport rates and free water transport are preserved.

Assisted PD throughout Europe: advantages, inequities, and solution proposals

BACKGROUND

Peritoneal dialysis provides several benefits for patients and should be offered as first line kidney replacement therapy, particularly for fragile patients. Limitation to self-care drove assisted peritoneal dialysis to evolve from family-based care to institutional programs, with specialized care givers. Some European countries have mastered this, while others are still bound by the availability of a volunteer to become responsible for treatment.

METHODS

A group of leading nephrologists from 13 European countries integrated real-life application of such therapy, highlighting barriers, lessons learned and practical solutions. The objective of this work is to share and summarize several different approaches, with their intrinsic difficulties and solutions, which might helpperitoneal dialysis units to develop and offer assisted peritoneal dialysis.

RESULTS

Assisted peritoneal dialysis does not mean 4 continuous ambulatory peritoneal dialysis exchanges, 7 days/week, nor does it exclude cycler. Many different prescriptions might work for our patients. Tailoring PD prescription to residual kidney function, thereby maintaining small solute clearance, reduces dialysis burden and is associated with higher technique survival. Assisted peritoneal dialysis does not mean assistance will be needed permanently, it can be a transitional stage towards individual or caregiver autonomy. Private care agencies can be used to provide assistance; other options may involve implementing PD training programs for the staff of nursing homes or convalescence units. Social partners may be interested in participating in smaller initiatives or for limited time periods.

CONCLUSION

Assisted peritoneal dialysis is a valid technique, which should be expanded. In countries without structural models of assisted peritoneal dialysis, active involvement by the nephrologist is needed in order for it to become a reality.

Peritoneal Dialysis Exit-Site Care Protocols in Portugal and Its Association with Catheter-Related Infections

INTRODUCTION

Exit-site infection (ESi) prevention is a key factor in lowering the risk of peritonitis. This study aimed to evaluate the associations between exit-site (ES) care protocols and the annual incidence rates of ESi and peritonitis in Portugal.

METHODS

We performed a national survey using two questionnaires: one about the incidence of catheter-related infections and the other characterizing patients' education and ES care protocols.

RESULTS

In 2017 and 2018, 14 Portuguese units followed 764 and 689 patients. ESi incidence rate was 0.41 episodes/year, and the peritonitis incidence rate was 0.37. All units monitor catheter-related infections on a yearly basis, use antibiotic prophylaxis at the time of catheter placement, and treat nasal carriage of S. aureus, although with different approaches. Screening for nasal carriage of S. aureus is performed by 12 units, and daily topical antibiotic cream is recommended by 6 out of 14 of the units. We did not find statistical differences in ESi/peritonitis, comparing these practices. The rate of ESis was lower with nonocclusive dressing immediately after catheter insertion, bathing without ES dressing, with the use of colostomy bags in beach baths and was higher with the use of bath sponge. The peritonitis rate was lower with bathing without ES dressing and if shaving of the external cuff was performed in the presence of chronic ESi.

CONCLUSIONS

We found potential proceedings associated with ESi and peritonitis. A regular national audit of peritoneal dialysis units is an important tool for clarifying the best procedures for reduction of catheter-related infections.

Protein Loss in Peritoneal Effluent: Different Meaning for 24-h versus PET Samples

INTRODUCTION

Quantification of peritoneal protein loss (PPL) may be expressed according to a timely collection (24-h measurement or 4-h PET assessment) and as a concentration. The aim of this study was to compare the quantification methods of 24-h and 4-h collections.

METHODS

This study included 81 prevalent peritoneal dialysis patients. Demographics and clinical and bioelectrical impedance features were registered. PPL was measured (4-h PET and 24-h results) and peritoneal protein clearance was calculated. A linear regression model was performed.

RESULTS

Age and continuous ambulatory peritoneal dialysis (compared to cycler) were positively associated with greater PPL on 24-h collections. Neither cardiovascular disease, hypertension, diabetes nor the comorbidity Charlson Index was significantly associated with PPL. There was a consistent univariable relationship with D/P creatinine, whichever sampling method was used. Only 24-h measurements of PPL correlated with body composition variables. In multiple linear regression analysis, D/P creatinine association with PPL stands out. On the other hand, 24-h determinations (in grams or clearance) were associated with overhydration. PET protein quantification was associated with peritoneal creatinine clearance.

DISCUSSION/CONCLUSION

Different methods sign different pathophysiological pathways. PET protein loss quantification should be regarded as a marker of peritoneal membrane intrinsic permeability. Measurements of a 24-h sample might be closer to patients' clinical status and prognosis, signalizing opportunities for therapy intervention.

Availability of assisted peritoneal dialysis in Europe: call for increased and equal access

INTRODUCTION

Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilised in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries.

METHODS

Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow, and their top 3 priorities.

RESULTS

Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD with all respondents mentioning need for nephrology team education and/or patient education and involvement in dialysis modality decision making.

CONCLUSION AND CALL TO ACTION

Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and for all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policy makers and healthcare providers to develop and support assistance for PD.

Peritoneal Protein Loss, Inflammation, and Nutrition: Refuting Myths

Peritoneal protein loss (PPL) has been correlated with mortality, malnutrition and inflammation. More recently overhydration was brought to the equation. This study aims to review classic and recent factors associated with PPL. Prevalent and incident peritoneal dialysis (PD) patients were included. Dialysate and serum IL-6 was obtained during PET. Hydration and nutritional status were assessed by bio-impedance. Linear regression and Cox regression were performed. The 78 included patients presented median values of PPL 4.8 g/24 h, serum IL-6: 5.1 pg/mL, and IL-6 appearance rate 153.5 pg/min. Mean extracellular water excess (EWexc) was 0.88 ± 0.94 L, and lean body mass index (LBMI) 17.3 ± 2.4 kg/m2. After mean follow-up of 33.9 ± 29.3 months, 12 patients died. Linear univariable analysis showed positive associations between PPL and small solute transport, body composition (LBMI and EWexc), comorbidities and performing CAPD (vs. cycler). PPL correlated positively with dialysate appearance rate of IL-6, but not with serum IL-6. Linear multivariable analysis confirmed positive association between PPL and EWexc (p = 0.012; 95%CI: 4.162–31.854), LBMI (p = 0.008; 95%CI: 1.720–11.219) and performing CAPD (p = 0.023; 95%CI: 4.375–54.190). In survival analysis, no relationship was found between mortality and PPL. Multivariable Cox regression showed Charlson Comorbidity Index (HR: 1.896, 95%CI: 1.235–2.913), overhydration (HR: 10.034, 95%CI: 1.426–70.587) and lower PPL (HR: 0.576, 95%CI: 0.339–0.978) were predictors for mortality. Overhydration, was a strong predictor of PPL, overpowering variables previously reported as determinants of PPL, namely clinical correlates of endothelial dysfunction or local inflammation. PPL were not associated with malnutrition or higher mortality, emphasizing the importance of volume overload control in PD patients.

Peritoneal Protein Loss, Inflammation, and Nutrition: Refuting Myths

Peritoneal protein loss (PPL) has been correlated with mortality, malnutrition and inflammation. More recently overhydration was brought to the equation. This study aims to review classic and recent factors associated with PPL. Prevalent and incident peritoneal dialysis (PD) patients were included. Dialysate and serum IL-6 was obtained during PET. Hydration and nutritional status were assessed by bio-impedance. Linear regression and Cox regression were performed. The 78 included patients presented median values of PPL 4.8 g/24 h, serum IL-6: 5.1 pg/mL, and IL-6 appearance rate 153.5 pg/min. Mean extracellular water excess (EWexc) was 0.88 ± 0.94 L, and lean body mass index (LBMI) 17.3 ± 2.4 kg/m2. After mean follow-up of 33.9 ± 29.3 months, 12 patients died. Linear univariable analysis showed positive associations between PPL and small solute transport, body composition (LBMI and EWexc), comorbidities and performing CAPD (vs. cycler). PPL correlated positively with dialysate appearance rate of IL-6, but not with serum IL-6. Linear multivariable analysis confirmed positive association between PPL and EWexc (p = 0.012; 95%CI: 4.162-31.854), LBMI (p = 0.008; 95%CI: 1.720-11.219) and performing CAPD (p = 0.023; 95%CI: 4.375-54.190). In survival analysis, no relationship was found between mortality and PPL. Multivariable Cox regression showed Charlson Comorbidity Index (HR: 1.896, 95%CI: 1.235-2.913), overhydration (HR: 10.034, 95%CI: 1.426-70.587) and lower PPL (HR: 0.576, 95%CI: 0.339-0.978) were predictors for mortality. Overhydration, was a strong predictor of PPL, overpowering variables previously reported as determinants of PPL, namely clinical correlates of endothelial dysfunction or local inflammation. PPL were not associated with malnutrition or higher mortality, emphasizing the importance of volume overload control in PD patients.

MO520: Prevalence of Anemia in Patients With Stage 3 or 4 Chronic Kidney Disease in Portugal–The Nefropor Study

BACKGROUND AND AIMS

Anemia is a highly prevalent and modifiable comorbidity in patients with chronic kidney disease (CKD), which tends to aggravate as the disease progresses. The economic burden of anemia in CKD is high, and quality of life issues (e.g. fatigue, reduced productivity) is common in these patients.

Data on the prevalence and treatment of anemia in CKD stages 3 and 4 (based on the estimated glomerular filtration rate according to KDIGO classification) in Portugal are lacking.

The NEFROPOR study aimed to estimate the prevalence of anemia in patients with CKD stage 3 or 4 admitted to a Nephrology consultation between 1 January and 31 March 2017 and characterize anemia treatment in this patient population.

METHODS

NEFROPOR was a retrospective, multicentric study carried out in 10 Portuguese centers. All patients aged ≥18 years with stage 3 or 4 CKD admitted to a Nephrology consultation in one of those centers between 1 January and 31 March 2017 were invited to participate, and data for up to 24 months after admission were collected from patients’ clinical files. Retrieved data included age, body mass index (BMI), anemia status according to the World Health Organization (WHO) diagnostic criteria, and anemia treatment type and duration. Three assessments of the prevalence anemia were performed: at the time of the first Nephrology visit (presentation), at the first analytical results and the overall prevalence in the study cohort. Statistical analysis was performed in SPSS Statistics (v26) and a 0.05 significance level was adopted.

RESULTS

A total of 176 patients were included in this study, mostly (61.9%) male, with a median age of 76 years (range, 26–97) and a mean BMI indicative of pre-obesity (28.2; standard deviation, 4.2). CKD stage 3b was predominant (43.2%), followed by stage 4 (32.4%) and stage 3a (24.4%). The most frequent CKD etiologies in this cohort were diabetes (39.8%), followed by arterial hypertension (27.8%) and unknown cause (25.6%). Arterial hypertension was largely the most frequent comorbidity, present in 90.3% of patients, followed by diabetes (54.0%). Although less prevalent, coronary artery disease (18.2%) and congestive heart failure (14.8%) were also identified in this patient population.

A total of 44.9% of patients [95% confidence interval (CI), 37.7%–52.3%] had anemia at presentation, which was significantly associated with CKD stage, diabetes, peripheral vascular disease and myocardial infarction comorbidities, and diabetes and unknown CKD etiology.

The overall prevalence of anemia in the study cohort was 61.9% (95% CI 54.6%–68.9%), and it was significantly associated with diabetes and peripheral vascular disease comorbidities and with diabetes and primary glomerulonephritis as CKD etiologies.

The prevalence of anemia at the first analytical results was 49.4% (95% CI 42.1%–56.8%), and it was significantly associated with CKD stage, diabetes, non-skin cancer, peripheral vascular disease and myocardial infarction comorbidities, and diabetes as CKD etiology.

Figure 1 shows the evolution of anemia treatment in this cohort over 24 + months.

CONCLUSION

The three estimates of the prevalence of anemia in this study were consistent with each other, particularly those for the first visit and first analytical results. The latter were also consistent with evidence in the literature reporting a prevalence of anemia in the population of patients with CKD stages 3 and 4 between 40% and 60%. The overall prevalence of anemia in this study was 12%–15% higher than first visit and first analytical results estimates, in agreement with the fact that this refers to a cumulative prevalence.

These data support the need for optimized and individualized treatment strategies for patients with CKD stages 3 and 4, maximizing the efficiency of health-care resource use.

MO695: Phase Angle: Clinical and Prognostic Value in Peritoneal Dialysis

BACKGROUND AND AIMS

Malnutrition–inflammation–atherosclerosis syndrome is common in chronic kidney disease and is associated with high mortality, particularly in dialysis patients. Bioimpedance analysis (BIA) is a simple and non-invasive method for nutritional assessment. The aim of this study was to evaluate the relationship between phase angle (PA) and other nutritional parameters and establish its role as predictor of mortality in peritoneal dialysis (PD) patients.

METHOD

Prevalent PD patients were enrolled in the longitudinal prospective study in a single tertiary center between 2015 and 2020, with a simultaneous BIA assessment and a modified peritoneal equilibration test. Spearman's correlation test was used to assess relevant clinical associations. Survival analysis was performed using the Kaplan–Meier test and univariate and multivariate Cox analysis to determine the predictive factors of all-cause mortality.

RESULTS

A total of 49 PD patients were included with mean age 55.9 ± 16.2 years, 57.1% male, Charlson comorbidity index 4.9 ± 2.3, Kt/V 2.5 ± 0.7, with a mean follow-up of 39.9 ± 26.3 months. The Spearman's correlation test showed a very strong positive association between PA and extracellular mass/body cell mass (r = 0.939, P < 0.001). It also showed a moderate positive association between PA and albumin (r = 0.524, P < 0.001) and normalized protein catabolism rate (r = 0.437, P = 0.002). Furthermore, PA was negatively correlated with age (r = −0.477, P = 0.001). In the Kaplan–Meier analysis, patients with PA < 4.9° had a lower survival rate (log rank = 4.77; P = 0.029). Using the multivariate Cox regression, forward model, PA (HR = 0.243; 95% CI 0.079–0.753), the number of cardiovascular events (HR = 11.236; 95% CI 1.286–98.211) and neutrophil–lymphocyte ratio (HR = 1.360; 95% CI 1.033–1.790) were predictors of all-cause mortality.

CONCLUSION

Lower PA appears to be associated with a decline in nutritional status, so monitoring it can be useful to identify patients at higher risk of malnutrition. PA was also validated as an independent predictor of mortality in our PD patients.

MO697: FGF-21 Correlates with Overhydration: Is There a Role for Peritoneal GLUT-1?

BACKGROUND AND AIMS

FGF-21 is a hepatokine that stimulates glucose uptake through GLUT-1. The presence of this glucose transporter in peritoneal fibroblasts is driven by peritoneal glucose exposure and is related to impaired ultrafiltration, predisposing to overhydration. The study was designed to determine FGF-21 levels in peritoneal effluent and serum, and its possible association with overhydration.

METHOD

Prevalent and incident peritoneal dialysis (PD) patients without diabetes were included. FGF-21 (dialysate and serum) was obtained during a 3.86% glucose peritoneal equilibration test. Peritoneal glucose load was calculated. The presence or absence of local peritoneal production was assessed by comparing the dialysate to plasma (D/P) ratio of FGF-21 (MW 32 kD) with that of albumin (MW 67 kD). Hydration status was assessed by bioimpedance. Spearman's correlations were performed.

RESULTS

A total of 58 patients (38 incident, 20 prevalent) were included, mean age 54 years, 67% males, PD duration from 1 to 75 months, mean 10.4. Residual GFR was 6.4 ± 3.5 mL/min/1.73 m2 and D/P creatinine 0.65 ± 0.12. Peritoneal glucose load was 110.5 g/day (range 40.8–226.9). Dialysate FGF-21 was 42.5 ± 47.0 pg/mL and serum FGF-21 943.9 ± 1164.8 pg/mL, giving a D/P ratio of 0.07. D/P albumin was 0.009, indicating that dialysate FGF-21 concentrations can be explained by transport from the circulation, without local peritoneal production. Serum FGF-21 was positively correlated with dialysate FGF-21, extracellular water excess and total peritoneal glucose load (all P < 0.01). Some association was present with PD duration (P < 0.05). No relationship was found between plasma FGF-21 and plasma insulin, D/P creatinine, or residual kidney function.

CONCLUSION

FGF-21 in peritoneal effluent is likely not locally produced, but caused by transport from the circulation. The associations between plasma FGF-21 levels with PD duration, peritoneal glucose load and overhydration, all indicate an effect of peritoneal glucose absorption from the peritoneal cavity into the interstitium with an insulin-independent storage into interstitial adipocytes, where it may stimulate the expression of GLUT-1.

MO688: Peritoneal Protein Clearance, Inflammation, Nutrition and Overhydration in PD Patients: Looking for the Culprit

BACKGROUND AND AIMS

Peritoneal protein loss has been for many years seen as a detrimental consequence of peritoneal dialysis (PD). Many studies correlated this leakage with mortality, malnutrition and inflammation. More recent knowledge has brought overhydration to this equation. This study aims to review classic and recent factors associated with peritoneal protein clearance and its consequences on overall mortality.

METHOD

Prevalent and incident PD patients were included. Interleukin 6 (IL-6; dialysate and serum) was obtained during a 3.86% glucose peritoneal equilibration test. Hydration and nutritional status was assessed by bioimpedance. Linear and Cox regression were performed.

RESULTS

A total of 78 patients were included (54 incident, 24 prevalent), the mean age was 54.6 ± 18.1 years, 65% were males, and the mean follow-up was 33.9 ± 29.3 months. The mean Charlson comorbidity index (CCI) was 4.4 ± 2.4. The residual GFR was 6.7 ± 3.6 mL/min/1.73 m2 and the D/P creatinine 0.65 ± 0.12. The IL-6 concentration in the dialysate was 24.9 ± 30.8 pg/mL and in serum was 37.3 ± 5.1 pg/mL. The phase angle was 5.4 ± 1.1°, overhydration 0.88 ± 0.94 L and peritoneal protein clearance 85.6 ± 54.7 mL/24 h. Overall, eight patients died.

Linear univariable analysis showed positive associations between peritoneal protein clearance and (i) small solute transport, as measured by D/P creatinine, (ii) body composition, as measured by phase angle and overhydration and (iii) CCI. The peritoneal protein clearance also correlated positively with dialysate IL-6, but not with serum IL-6. By linear multivariable analysis, using the backward method, a significant positive association between peritoneal protein and overhydration (P < 0.001; IC:26.665–71.694) and also phase angle (P = 0.032; IC: 1.845–39.330) were validated.

In the exploratory survival analysis, no relationship was found between mortality and peritoneal protein clearance. A univariable positive association was shown with serum IL-6 concentration, overhydration and CCI. A higher phase angle was associated with lower mortality. No relationship with dialysate IL-6 or D/P creatinine was found. In this early-stage PD population, with globally preserved residual kidney function, an effect of this variable on mortality was not evident.

Cox regression, conditional backward method, showed CCI (OR: 1.896, IC: 1.235–2.913, P = 0.003), overhydration (OR: 10.034, IC: 1.426–70.587, P = 0.021) and peritoneal protein clearance (OR: 0.576, IC: 0.339–0.978, P = 0.041) were predictors for mortality.

CONCLUSION

A better nutrition status and overhydration are the major determinants of peritoneal protein clearance. The survival analysis showed that mortality is higher in overhydrated patients, with higher CCI, but not with higher peritoneal protein clearance. Inflammation, local or systemic, as assessed by IL-6 concentration, did not reveal to be such a strong prognosis predictor as overhydration in these PD patients.

MO754: Impact of Calcium-to-Magnesium Ratio on Carotid Intima-Media ThicknessCardiovascular Risk Assessment in Haemodialysis

BACKGROUND AND AIMS

Cardiovascular disease (CVD) is the leading cause of death in chronic kidney disease patients. The interaction between calcium and magnesium has been associated with several pathophysiological processes that occur in the vessel wall, such as endothelial dysfunction and vascular calcification. The aim of this study was to assess the relationship between calcium-to-magnesium (Ca: Mg) ratio and carotid intima-media thickness (CIMT), a widely used risk marker for CVD in the assessment of subclinical atherosclerosis. This study also aimed to establish the role of the Ca: Mg ratio as a predictor of cardiovascular mortality in haemodialysis (HD).

METHOD

Prevalent HD patients were enrolled in the longitudinal prospective study in a single tertiary centre. According to CIMT measured through B-mode ultrasound, the patients were divided into two groups: ≥0.9 mm (G1) and <0.9 mm (G2). Data from both groups were compared by Student's t-test. Partial correlation was used to assess the relationship between the variables under analysis and the CIMT, when controlled by dialysis time. The prevalence ratio of predictors of carotid thickening was calculated using a Poisson model with robust variance. Multivariable Cox regression analysis was performed to determine the predictive factors of cardiovascular death.

RESULTS

A total of 120 patients on HD were included with mean age 66.5 ± 13.97 years, 66.7% male. Magnesium (P < 0.001), Ca: Mg ratio (P < 0.001) and Adragão score (P <0.001) were statistically different between the two groups (Table 1). The partial correlation showed a strong positive association between CIMT and Ca: Mg ratio (r = 0.873; P <0.001) and a moderate association between CIMT and Adragão score (r = 0.614, P < 0.001), whereas there was a moderate negative correlation between CIMT and magnesium (r = –0.671, P <0.001). The Poisson model showed high prevalence of carotid thickening for higher values ​​of Ca: Mg ratio [aPR = 1.055, 95% confidence interval (95% Cl) 1.007–2.176] and Adragão score (aPR = 1.106, 95% Cl 1.006–1.351), and for lower magnesium values ​​(aPR = 0.462, 95% CI 0.248–0.861). Using the multivariate Cox model, age (HR = 1.045, 95% CI 1.012–1.084), Adragão score (HR = 1.078, 95% CI 1.006–1.234) and Ca: Mg ratio (HR = 1.154, 95% CI 1.098–2.236) were predictors of cardiovascular mortality.

CONCLUSION

In our population, the Ca: Mg ratio was a predictor of carotid thickening, so its monitoring can be useful to identify patients at higher cardiovascular risk. The Ca: Mg ratio was further validated as a predictor of cardiovascular mortality in HD patients. More studies are needed to better understand the relationship between this ratio and cardiovascular events.

Overhydration May Be the Missing Link between Peritoneal Protein Clearance and Mortality

INTRODUCTION

Peritoneal protein loss (PPL) has been associated with mortality. Inflammation was assumed a putative cause with malnutrition as a consequence. Hydrostatic convection is a major drive for microvascular protein transport, but most studies in peritoneal dialysis (PD) patients overlooked this mechanism. An association between peritoneal protein clearance (PPCl) and venous congestion has been reported recently. The aim of this study was to explore the importance of fluid overload in PPCl in PD.

METHODS

Sixty-seven prevalent PD patients were assessed with peritoneal equilibration test and multifrequency bioelectrical impedance assessment (BIA). PPL and PPCl were calculated from simultaneously obtained 24-h peritoneal effluent.

RESULTS

PPL averaged 5.2 g/24 h. It was higher in patients on continuous treatment than in those without a long dwell. Significant associations between PPCl and BIA parameters of overhydration were found in both univariable and multivariable analyses. Lean mass index, partly dependent on hydration status, was associated with PPCl in univariable but not in multivariable analysis. A multiple linear model identified extracellular water excess and higher D/P creatinine as predictors of higher PPCl, independent of PD duration, type of PD, age, gender, albumin, cardiovascular disease, C-reactive protein, or lean mass index.

CONCLUSIONS

The uni- and multivariable strong associations between fluid overload and PPCl support the importance of hydrostatic pressure-induced convection for PPCl. Also, peritoneal small solute transport was associated with PPCl. Both are amenable by adjusted dialysis prescription, especially focused on fluid status and avoidance of overhydration. The assumption of an association with inflammation and malnutrition was not confirmed.

P1200PERITONEAL PROTEIN LOSSES: WHAT DO WE MEAN

Background and Aims

The report of peritoneal protein loss should be related with a timely collection (24-hour measurement or 4-hour PET assessment) or concentration. Standardized and reproducible estimation of peritoneal protein transport is obtained during PET. The 24-hour measurements estimate the real amount of PPL, but may be affected by other factors unrelated to the prognosis of PD patients, as inconsistencies in collection and management of the samples. Overall, PET protein loss quantification may be a more specific marker of peritoneal large-pore dysfunction and is seemingly more convenient than 24-hour measurements. The aim of this study was to compare the results of both sampling methods.

Method

A total of 144 adult incident PD patients were included. A standard peritoneal equilibration test, 24-hour urine and dialysate collection, and multifrequency bioimpedance analysis were performed. Independent-samples t test and Pearson correlation coefficient were performed to evaluate relevant clinical associations.

Results

Statistically significant univariable relationships for 24h PPL were found for continuous ambulatory PD technique (CAPD) and, with a correlation coefficient >0.20, for pulse pressure, 4-hour dialysate/plasma creatinine and extracellular water/total body water. Studying 240 min PPL, only with 4-hour dialysate/plasma creatinine, creatinine clearance and bicarbonate levels were statistically significant. In both samples there was no significant association with age, gender, type of effluent (biocompatible solutions or lactate plus bicarbonate comparing with bicarbonate), comorbidity Charlson Index, or presence of diabetes. Correlation between 240 min PPL and 24h PPL ensues, but it is not strong (p<0.001; r=0.365).

Conclusion

The weak correlation between 24h and 240 minutes show that these two measurements should not be considered equivalent. Measurements of a 24h sample might be more close to patients’ clinical status and prognosis, despite more frequent sampling errors. PET protein loss quantification should be regarded as a marker of peritoneal large-pore dysfunction.

P1507COMPETING RISKS MODELING IN PERITONEAL DIALYSIS: THE URGE FOR A CHANGE IN SURVIVAL ANALYSIS METHODOLOGY

Background and Aims

Survival analysis is a cornerstone in medical research. For this purpose Kaplan-Meier is the most widely used statistical test, but the presence of competing risks violates the fundamental assumption that the censoring mechanism is independent of survival time. This leads to overestimation of the cumulative probability of cause-specific failure. Cumulative incidence estimate and competing risks analysis are preferred. The purpose of this study was to compare different survival analysis methods: Kaplan-Meier and cumulative incidence function estimates in a cohort of Peritoneal Dialysis (PD) patients.

Method

The survival of 115 incident patients on PD in a university hospital was evaluated after establishing 2 cohorts: patients starting renal replacement therapy with PD (PD first; n=85) and patients switching to PD on the first 6 months of dialysis (PD transfer; n=30). Kaplan-Meier, cumulative incidence function, cause-specific and subdistribution hazards were performed. The event of interest was death and the competing risk events were transfer to hemodialysis and renal transplantation.

Results

Besides higher residual renal function (RRF) and kt/V in the PD first group, there were no other significant differences between groups. There were 22 deaths. PD first group had a better survival with both Kaplan-Meier (log-rank test, p=0.013) and cumulative incidence function (p=0.021) approaches. The Cox regression model showed, as protecting variables, higher albumin (HR=0.174; CI95% 0.054-0.562), higher RRF (HR=0.785; CI95% 0.666-0.925) and PD first (HR=0.350; CI95% 0.132-0.927). Higher Charlson Index predicted worse outcome (HR=1.459; CI95% 1.159-1.835). PD as first dialysis therapy was associated with 65.0 % lower risk of death comparing with PD transfer. The subdistribution multivariable model found higher Charlson Index (HR=1.389; CI95% 1.118-1.725) and lower RRF (HR=0.798; CI95% 0.680-0.936) were statistically associated with death, but not PD transfer or albumin. This result differs from the obtained using the cause-specific hazard model. Analyzing the competing events, patients submitted to renal transplantation had a lower Charlson Index.

Conclusion

The probability of death was overestimated by the Kaplan-Meier method. The bias of Kaplan-Meier is especially great when the hazard of the competing risks is large. This study consisted on a statistical critical analysis of a real medical example, broader clinical conclusions related with “PD first initiative” should be cautious in this context.

It is primordial to recognize the presence of competing risks in studies with multiple outcomes, as in Peritoneal Dialysis studies, to estimate cumulative incidence and yield more accurate results. This study shows how different conclusions are attained with different statistical methodology and its relevance in clinical context.

P1209ROLE OF NTPROBNP IN LONG-TERM PERITONEAL DIALYSIS PATIENTS

Background and Aims

Plasma N-terminal fragment of pro brain natriuretic peptide (NTproBNP) concentration is elevated in cardiovascular diseases such as congestive heart failure, where increased levels of NTproBNP indicate cardiac dysfunction, hypervolemia, and higher risk of hospitalization and death. These associations have also been studied in patients with chronic kidney disease (CKD), where NTproBNP value remains controversial, especially in long-term peritoneal dialysis (PD) patients with respect to its pathophysiologic implications. This study aim was to determine whether NTproBNP was a predictor of hospital admissions and cardiovascular events among patients on automated (APD) and continuous (CAPD) ambulatory peritoneal dialysis.

Methods

This was a cross-sectional study which included stable patients from two Peritoneal Dialysis Units. Plasma NTproBNP concentration was measured in stable adult peritoneal dialysis patients attending for routine assessments on PD outpatient clinic.

In all patients, demographic variables, clinical and other laboratory parameters were recorded and analyzed. Descriptive statistics was performed. Groups were compared using independent t-test for comparison of continuous variables and Chi square test for categorical variables. In order to evaluate relationship between NTproBNP and the other variables multivariate logistic regression and Pearson bivariate analysis were used.

Results

The study enrolled 70 patients (male/female 44/26; mean age 55.3±14.6 years; APD/CAPD 25/45; PD duration 28±24.2months). One third (31.4%) of the patients was diabetic, 12.9% presented cardiac insufficiency and 20% had cardiovascular disease. Pearson bivariate correlation analysis revealed that patients with higher weekly kt/v (p=0.039), total fluid removal (diuresis and ultrafiltration) (p=0.027) and total weekly creatinine clearance (p=0.007) had lower NTproBNP values. These patients had also significant lower plasmatic creatinine and phosphorus levels. We found no significant association with residual kidney function, peritoneal transport (D/P creatinine), serum albumin levels and c-reactive protein.

We also found that patients with higher NTproBNP levels had significantly more cardiovascular events (p=0.010) and a trend for more common hospital admissions (p=0.066).

There were no significant differences regarding NTproBNP between the two modalities of peritoneal dialysis (APD and CAPD patients) or in patients who were PD first.

As expected, patients with cardiac dysfunction had significant higher NTproBNP values (p=0.004). Diabetic patients had higher NTproBNP levels, althought this difference was not significant.

Conclusion

Despite the inconsistency in the NTproBNP value among long-term PD patients, results from most studies concur that NTproBNP levels are closely associated with left ventricular dysfunction, morbidity and mortality in these patients. In our study, patients with higher NTproBNP levels had more cardiovascular events and a trend for more common hospital admissions. Regular monitoring of NTproBNP levels among PD patients may be useful for providing care for these patients. Plus, NTproBNP was associated with better PD efficacy, greater fluid removal and higher creatinine clearance, reinforcing clinical relevance of PD optimization. These results require confirmation in a prospective study.

P1191PREDICTORS FOR QUALITY OF LIFE IN AUTOMATED AND CONTINOUS AMBULATORY PERITONEAL DIALYSIS

Background and Aims

Quality of life (QoL) influences the morbidity and mortality in End-Stage Kidney Disease (ESKD) patients on dialysis and is increasingly well recognized as an important measure of treatment outcome. Identification of the factors that influence QoL in patients receiving peritoneal dialysis (PD) can help improving their management. This study was carried out to determine the clinical, biochemical and psychological predictors for QoL scores among ESKD patients on automated (APD) and continuous (CAPD) ambulatory peritoneal dialysis.

Methods

This was a cross-sectional study which included stable patients from two Peritoneal Dialysis Units. We excluded patients who weren’t able to understand the questionnaires, the language and the ones who had hospitalar admissions in the previous 3 months. Quality of life parameters were assessed by self-administered EuroQol questionnaire (EQ-5D-5L) - higher scores indicate better QoL; Pittsburg Sleep Quality Index (PSQI) was used for assessing sleep quality and evaluation of each patient’s depressive symptoms was made with Patient Health Questionnaire (PHQ-9). In all patients, demographic variables, Charlson Comorbidity Index (CCI), clinical and laboratory parameters were recorded and analyzed. Descriptive statistics was performed. Groups were compared using independent t-test for comparison of continuous variables and Chi square test for categorical variables. In order to evaluate relationship between QoL and the other variables multivariate logistic regression and Pearson bivariate analysis were used.

Results

The study included 70 patients (male/female 44/26; mean age 55.3±14.6 years; APD/CAPD 25/45; PD duration 28±24.2months). Mean CCI was 4.59±1.86; 31.4% of the patients were diabetic, 12.9% presented cardiac insufficiency and 20% had cardiovascular disease. We found that EuroQoL score was significantly associated with Pittsburg Sleep Quality Index (p=0.001), depression score (PHQ-9) (p<0.001), nPCR (p=0.006), duration of PD (p=0.017) and patients’ perception of their own well-being (P=0.002). Comparing EuroQol Score between genders, males had a significant lower score (p=0.011). We found no association with N-terminal pro-brain natriuretic peptide (NTproBNP), overhydration, residual renal function, weekly KT/V and hospital admissions. There were no significant differences regarding EuroQol score between the two modalities of peritoneal dialysis (APD and CAPD patients) or in patients who were PD first.

We also found that the patients with lower EuroQol Score were significantly more depressed (p<0.001) and had poorer sleep quality (p<0.001). Sleep quality wasn’t associated with hypertension or cardiovascular disease. There was no significant difference concerning to age and CCI between the group of patients with worst QoL (EuroQol<0.212) and better QoL (EuroQol Score>0.961).

Plus, there were no significant differences in the EuroQol score in patients with cardiovascular disease.

In a multivariate analysis (linear regression) there was a significant association between EuroQol and depression (B=-0.346; IC 95% -0.022 to -0.004; p=0.004), nPCR (B=-0.417; IC 95% -0.254 to -0.072; p=0.001) and duration of PD (B=-0.351; IC 95% -0.004 to-0.001; p=0,004).

Conclusion

Poor sleep quality, presence of depression and lower nPCR are associated with poorer quality of life. In order to improve life quality in PD patients, quality of sleep, depression and nutritional status should be serially evaluated and given appropriate treatment when required.

P1153ARE LONG-TERM PERITONEAL DIALYSIS PATIENTS SLEEPING WELL?

Background and Aims

Sleep quality is an important and determining factor in the quality of life (QoL) during dialysis. The prevalence of sleep disorders in the general population varies between 10 and 40%; this figure increases to 50% in dialysis patients.

This study was conducted to determine which factors influence sleep quality in end stage renal disease patients on automated (APD) and continuous (CAPD) ambulatory peritoneal dialysis.

Methods

This was a cross-sectional study which included stable patients from two Peritoneal Dialysis Units. We excluded patients who weren’t able to understand the questionnaires, the language and the ones who had hospitalar admissions in the previous 3 months. Pittsburg Sleep Quality Index (PSQI) was used for assessing sleep quality (the higher the score, the lower the sleep quality), while quality of life parameters were assessed by self-administered EuroQol questionnaire (EQ-5D-5L). The presence of depressive symptoms was made with Patient Health Questionnaire (PHQ-9). In all patients, demographic variables, Charlson Comorbidity Index (CCI), clinical and laboratory parameters were recorded and analyzed. Descriptive statistics was performed. Two groups were created according to Pittsburg Sleep Quality score: G1 (n=42) - “poor” sleep quality and G2 (n=28) - “good” sleep quality. Groups were compared using independent t-test for comparison of continuous variables and Chi square test for categorical variables. In order to evaluate relationship between sleep quality and the other variables multivariate logistic regression and Pearson bivariate analysis were used.

Results

The study enrolled 70 patients (male/female 44/26; mean age 55.3±14.6 years; APD/CAPD 25/45; PD duration 28±24.2months). One third (31.4%) of the patients was diabetic, 12.9% presented cardiac insufficiency and 20% had cardiovascular disease. 50% of our population had a sleep disorder, although the majority of the problems were slight to moderate.

We found that PD patients who sleep better (G2) had significant better life quality (p<0.001), lower CCI (p<0.001) and were less depressed (p<0.001). 77.3% of the patients with worst sleep quality (G1) were diabetic (p=0.04), regardless glycemic control and hemoglobin A1c.

There were no significant differences between the two modalities of peritoneal dialysis (APD and CAPD patients), between genders or in patients who were PD first. We found no significant association between sleep quality and dialysis efficacy (weekly kt/v).

Multivariate analysis (linear regression) showed a significant association between sleep quality and EuroQol (ExpB=0.000; IC 95% 0.000 to 0.054; p=0.002) and, depression (ExpB=1.274; IC 95% 1.045 to 1.552; p=0.017) in a model adjusted to age, PD duration and diabetes.

Conclusion

Our results show that poor sleep quality seems to be linked to life quality, comorbidity burden and depression. A better understanding of risk factors associated with poor sleep quality may help to signalize the patients who may benefit of specific treatment. The PSQI survey is a simple tool offering very complete information on sleep quality. The implementation of actions aimed at improving the hygiene of sleep may be an excellent way to improve the patients’ quality of life in an efficient and effective manner.

P1232COMPUTED TOMOGRAPHIC PERITONEOGRAPHY - GUARANTYING SAFER SURGICAL STRATEGIES

Background and Aims

Peritoneal Dialysis (PD) is currently the first option as renal replacement therapy to many patients, for several reasons, as personal flexibility, volemic management in cardiorenal patients, poor vascular access to dialysis, among others. Mechanical complications can be a drawback in these patients, which may occur during or after catheter placement. Abdominal wall hernias and dialysate leaks are relatively common and highly related to chronically increased intraperitoneal pressure. In this setting CT peritoneography is the technique of choice as it allows differentiation between a true hernia or a wall leakage.

Method

We describe a case of a 69-year-old man, with a personal history of polycystic kidney disease, colonic diverticulosis and hypertension, which opted for PD. The patient later developed a mechanical complication for which a proper diagnostic approach, namely through specific imaging, and surgical planning were essential.

Results

After 15 months without complications, it was detected a bulging in the periumbilical area, exacerbated by orthostatism. Changes in dialytic prescription included lower dialytic volumes during orthostatic period, with some improvements. The limitation of volumes and difficulty of drainage were limiting dialytic prescription and insufficient kt/V. An ultrasound (figure 1) and CT peritoneography (figure 2) were performed, revealing an hernial sac with peritoneal liquid leak, without any intestinal loop, approachable by minimally invasive surgery and local anesthesia.

Mini-laparotomy was performed, hernial sac was removed, without peritoneum aperture, with only a 4-day pause on PD technique.

Conclusion

CT peritoneography allowed the differentiation between this true hernia and a wall leakage, by providing accurate anatomical detail, allowing proper planning of surgical intervention. In this case, the patient had additional predisposing factors, namely polycystic kidney disease. Moreover, only a short pause on PD was necessary. Although some limitations exist, such as the use of iodinated contrast material and ionizating radiations, CT peritoneography is currently the gold standard for the evaluation of mechanical complications in PD; in addition to those mentioned, it is also useful for complications related to the catheter (kinking, entrapment, malposition), intrabdominal adhesions or loculated fluid collections.

P1172IS PERITONEAL PROTEIN LOSS A CONSEQUENCE OF OVERHIDRATATION?

Background and Aims

Peritoneal protein loss (PPL) in peritoneal effluent is a well-recognised detrimental result of peritoneal dialysis treatment since its inception. Hydrostatic convection is a major drive for peritoneal protein transport; therefore venous congestion may have a role in peritoneal protein loss (Krediet RT et al Perit Dial Int. 2019 ). The aim of this study was to explore the importance of overhydration on the magnitude of peritoneal protein clearance in incident PD patients.

Method

A total of 97 adult incident PD patients were included. A standard peritoneal equilibration test, 24-hour urine and dialysate collection, and multifrequency bioimpedance analysis were performed. Independent-samples t test and Pearson correlation coefficient were performed to evaluate relevant clinical associations and linear multivariable regression was done.

Results

Statistically significant univariable relationships for 24h PPL were found for continuous ambulatory PD technique (CAPD) and, with a correlation coefficient >0.20, for age, pulse pressure, 4-hour dialysate/plasma creatinine and extracellular water/total body water. On multivariable analysis, type of PD technique (β=0.327, p=0.011), 4-hour dialysate/plasma creatinine (β=0.247, p=0.037), and extracellular water/total body water (β=0.304, p=0.016) were significant independent predictors of peritoneal protein loss.

Conclusion

Overhydration revealed the most important connection with peritoneal protein loss. Mortality has been associated with PPL in some studies, but not others. This could be a result of this relationship, as volume overload has been strongly related with lower survival.

P1132EXIT-SITE CARE PROTOCOLS IN PORTUGAL AND ITS ASSOCIATION WITH CATHETER-RELATED INFECTIONS RATE

Background and Aims

Exit-site infections (ESi) are frequent complications in peritoneal dialysis (PD) patients and their prevention and treatment are key aspects to lower peritonitis’ risk.

The aim of this study was to evaluate the annual incidence rate of ESi and peritonitis in Portugal and to study possible associations between exit-site (ES) care protocols in each Portuguese unit and the number / rate of ESi and peritonitis.

Method

We performed a national study using two questionnaires at each Portuguese PD Unit: one about the incidence of catheter-related infections, the other characterizing patients’ education and ES care protocols. ESi and peritonitis were defined according to ISPD guidelines. Associations between variables were performed using T-student test or pairwise correlation test. STATA software was used.

Results

Of the 23 Portuguese PD Units, 14 units answered both questionnaires. In the last two years (2017 & 2018), those units followed 1453 patients. Portuguese ESi incidence rate was 0.41 episodes per year [1 episode per 29.2 months (MSSA incidence rate 0.13; MRSA incidence rate 0.03; Pseudomonas incidence rate 0.07)] and the peritonites incidence rate was 0.37 (1 episode per 32.5 months). We found a trend between the absolute number of ESi episodes and the number of peritonites in each unit (r=0.5, p=0.05).

Although ESi prevention guidelines were known by 100% of the Portuguese units, only three out of 5 of the selected guidelines for this study were followed by 100% of the units: monitoring catheter-related infections on a yearly basis; using antibiotic prophylaxis at time of catheter placement and treating nasal carriage of S. aureus. The other 2 guidelines have variable implementation: 12 out of 14 units (86%) perform screening of nasal carriage of S. aureus and only 6 out of 14 (43%) of the units recommend daily topic antibiotic cream at the ES. We didn’t find associations between those differences and ESi incidence.

Whenever S. aureus carriage is detected, 100% of the units proceed treating with mupirocine using different posology (twice or three times a day, 5 or 7 or 21 days, with/out chlorexidine). Also, the screening of nasal carriage of S. aureus is different: only pre catheter implantation (n=4); annually (n=4); semi annually (n=3); bimonthly (n=2). Oral antibiotics are prescribed after catheter placement in 4 units. We didn’t find statistical differences in ESi / peritonitis, comparing those practices.

Regarding to ES care protocols, ESi rate was lower with non-occlusive dressing (0.38 vs. 0.57) immediately after catheter insertion. ESi and peritonitis rate were lower in units where bathing without ES dressing is advocated (n=9, 0.58 & 0.37 vs. 0.32 & 0.34). The use of bath sponge is associated with higher ESi rate (0.57 vs. 0.34). The use of colostomy bags in beach baths was associated with lower incidence rate of ESi compared to regular dressing or waterproof dressing (o.32 vs. 0.54).

100% of units use two different empirical antibiotics for initial ESi treatment. In the presence of chronic ESi, 3 units don’t perform shaving of external cuff and peritonitis rate is higher in those who do not apply this procedure (0.38 vs. 0.31).

Conclusion

in Portuguese PD units there is a wide variability in ISPD guidelines implementation and ES care protocols. We found that using non-occlusive dressing immediately after catheter insertion, removing ES dressing before shower, bathing not using a sponge and using colostomy bags at beach baths were associated with lower incidence rate of ESi. Shaving of the external cuff was associated with lower incidence rate of peritonitis. A regular national audit of PD Units is an important tool of quality improvement to clarify the best procedures for reduction of catheter-related infections in PD.

[Peritoneal Dialysis in the Current Pandemic Crisis: An Opportunity for Reflection]

N/a.

Persistent exit-site infection in peritoneal dialysis - An unrecognized window to abdominal viscera

Exit-site (ES) infection is a common complication in peritoneal dialysis (PD). Pseudomonas spp. is particularly difficult to treat, and catheter removal should be considered in persistent infections. The authors present a chronic ES infection resistant to directed antibiotic therapy in which catheter salvage was not possible. Removal was very difficult due to the presence of white sponge-like tissue with petrous consistency surrounding the catheter, all the way into the peritoneum. Histology revealed well-differentiated adenocarcinoma infiltrates. Abdominal computed tomography scan revealed a solid pancreatic (tail) lesion, nodular images on the greater epiploon, an adnexal lesion and a hepatic solid lesion, consistent with metastasis. The patient was referred for palliative care but maintained PD until untreatable pain and deterioration of general status aroused. Somewhere along the course of a chronic ES infection, the peritoneal catheter (and inflammation) was the metastatic path of an unknown pancreatic cancer, with neoplastic tissue reaching the skin. Catheter removal was crucial for diagnosis.

Peritoneal Protein Loss, Leakage or Clearance in Peritoneal Dialysis, Where do we Stand?

Peritoneal protein loss (PPL) through peritoneal effluent has been a well-recognized detrimental result of peritoneal dialysis (PD) treatment since its inception. Investigation has focused mainly on PPL quantitative and qualitative determinations and evaluation of its prognostic value.

A comprehensive review of the pathophysiology of PPL (3-pore model revisited), methods of quantification, dialysate protein composition, and impact on clinical outcomes is presented herein. The author summarizes a brief analysis of associated cardiovascular disease and nutritional consequences, exploring the controversial cause-effect on mortality and technique failure.

Therapeutic modalities aiming to reduce PPL (angiotensin-converting enzyme inhibitors [ACEI]s and vitamin D therapies) were explored, although it is unclear whether PPL represents a valid therapeutic target or, on the other hand, is solely a manifestation of endothelial dysfunction.

Paricalcitol and Peritoneal Protein Loss in Peritoneal Dialysis: A Double-Center Study

BACKGROUND/AIMS

Peritoneal protein loss (PPL) is associated with cardiovascular disease and mortality in peritoneal dialysis (PD). Controversial results have been published about the effect of paricalcitol in PPL among PD patients. This study intends to analyze the relationship between paricalcitol and PPL in PD.

METHODS

In a retrospective study, prevalent PD patients were divided into 2 groups: "with paricalcitol" and "without paricalcitol". X2-test, Student's t test, Pearson correlation coefficient and Logistic Regression analysis were applied.

RESULTS

Eighty-two patients were included. PPL was lower among patients medicated with paricalcitol (5.17 ± 1.71 vs. 6.79 ± 2.10 g/24 h, p = 0.0001). In multivariate analysis, paricalcitol and dialysate/plasma ratio of creatinine (D/P creatinine) were independently related to PPL (OR 4.270 [1.437-12.684], p = 0.009 and OR 0.205 [0.064-0.659], p = 0.008, respectively), adjusted for diabetes.

CONCLUSION

Paricalcitol and D/P creatinine were independently related to PPL. Paricalcitol may have an effect on PPL in PD patients.

[Obesity and the kidney]

Obesity represents an important risk factor for the development of chronic kidney disease (CKD), due to its known strong association with diabetes mellitus and hypertension, the two major causes of CKD, but also as an independent renal risk factor. This direct relationship between obesity and kidney injury has been undervalued. The aim of this revisión is to point out the mechanisms of kidney injury induced by obesity, underline the importance of this association and alert for the prevention, education and treatment of the obese patient, as a way to control this heavy modifiable risk factor.