Histological and clinical findings in patients with post-transplantation and classical encapsulating peritoneal sclerosis: a European multicenter study

BACKGROUND

Encapsulating peritoneal sclerosis (EPS) commonly presents after peritoneal dialysis has been stopped, either post-transplantation (PT-EPS) or after switching to hemodialysis (classical EPS, cEPS). The aim of the present study was to investigate whether PT-EPS and cEPS differ in morphology and clinical course.

METHODS

In this European multicenter study we included fifty-six EPS patients, retrospectively paired-matched for peritoneal dialysis (PD) duration. Twenty-eight patients developed EPS after renal transplantation, whereas the other twenty-eight patients were classical EPS patients. Demographic data, PD details, and course of disease were documented. Peritoneal biopsies of all patients were investigated using histological criteria.

RESULTS

Eighteen patients from the Netherlands and thirty-eight patients from Germany were included. Time on PD was 78(64-95) in the PT-EPS and 72(50-89) months in the cEPS group (p>0.05). There were no significant differences between the morphological findings of cEPS and PT-EPS. Podoplanin positive cells were a prominent feature in both groups, but with a similar distribution of the podoplanin patterns. Time between cessation of PD to the clinical diagnosis of EPS was significantly shorter in the PT-EPS group as compared to cEPS (4(2-9) months versus 23(7-24) months, p<0.001). Peritonitis rate was significantly higher in cEPS.

CONCLUSIONS

In peritoneal biopsies PT-EPS and cEPS are not distinguishable by histomorphology and immunohistochemistry, which argues against different entities. The critical phase for PT-EPS is during the first year after transplantation and therefore earlier after PD cessation then in cEPS.

Should the medicare ESRD program pay for daily dialysis? An ethical analysis

End-stage renal disease (ESRD) is a growing problem in the United States and has now reached epidemic proportions. The mortality rate and other complications related to conventional dialysis remain unacceptably high necessitating improvements in dialytic therapies. One strategy has been to increase dialysis frequency through daily dialysis since the Hemodialysis study showed that clinical outcomes are not improved by simply increasing delivered dialysis dose per session. Most studies of daily dialysis are observational and limited by small sample size, variable dialysis techniques, high patient dropout, and lack of adequate control group. These studies have shown consistent improvements in blood pressure and solute clearance, but improvements in patient survival, anemia, and health-related quality of life are less clear. The costs of providing daily dialysis on a large scale are likely to be substantial. However, if there are significant improvements in the outcome measures outlined earlier as well as decreased hospitalization rates, daily dialysis may prove cost-effective or budget neutral from a global standpoint. A scientific basis is needed to justify a change in the Medicare ESRD Program to fund daily dialysis. Decisions regarding the allocation of limited medical resources such as the Medicare budget should consider ethically appropriate criteria including likelihood of benefit, urgency of need, change in quality of life, duration of benefit, patient selection, equitable distribution, and the amount of resources required. In examining the evidence base on daily dialysis according to these ethical criteria, we find that there are not yet sufficient grounds to recommend funding of daily dialysis by the Medicare ESRD Program. Randomized controlled trials comparing conventional hemodialysis to short daily and long nocturnal hemodialysis are much needed.

Traditional and "new" cardiovascular risk markers and factors in pediatric dialysis patients

Cardiovascular disease (CVD) is the principal cause of mortality in patients with end-stage renal disease (ESRD). The aim of this study was to analyze carotid intima-media thickness (cIMT), endothelium-dependent dilatation (EDD), and left ventricular mass index (LVMI) as the cardiovascular risk markers and to investigate the independent risk factors of these markers in pediatric dialysis patients. This study included 39 children and adolescents undergoing dialysis (15 hemodialysis and 24 peritoneal dialysis) and 15 age- and gender-matched healthy subjects. The cIMT and EDD were assessed by high-resolution ultrasound, and LVMI was calculated from standard echocardiographic measurements. Compared with control subjects, cIMT standard deviation scores (SDS), LVMI, total homocysteine (tHcy), and high-sensitivity C-reactive protein (hs-CRP) values were significantly higher in patients, but EDD values did not differ. The mean hs-CRP level was significantly higher in hemodialysis (HD) patients than in peritoneal dialysis (PD) patients. The cIMT-SDS and LVMI were associated with several variables in univariate analysis. Stepwise linear regression analysis, indexed SBP (p = 0.017), and hemoglobin (p = 0.001) turned out to be independent variables for predicting LVMI, and a significant predictor of cIMT was indexed diastolic blood pressure (DBP) (p = 0.035). The causes of atherosclerosis and left ventricular hypertrophy are multifactorial in children and adolescents with ESRD. Better management of hypertension and anemia may be priorities for preventing or improving CVD in these patients.

[Survival of patients starting dialysis at an advanced age in the Piedmont]

BACKGROUND

Patients starting dialysis in old age (age > 70 and > 80) in Piedmont are widely increasing: the survival curves of this group of patients can give very important information to evaluate the quality of both the delivered therapy and our very wide criteria of acceptance to the treatment. To this end, using data from the Piedmont Dialysis and Transplant Register, the survival curves of patients with age over 70 and 80, beginning dialysis in all Piedmont Dialysis Units between 1981 and 1996, have been examined.

METHODS

These curves have been considered both in a general way and according to the presence or absence of further high risk conditions; they show results better than expected and improving from 1981 to 1995.

RESULTS

If the survival curves of these patients are considered according to the kind of dialytic treatment performed, they do not show any significative difference.

CONCLUSIONS

The conclusion is drawn that these data strongly support first, the fitness of criteria of very wide acceptance to the treatment and modulated choice of the kind of dialytic treatment at present followed in Piedmont; and second, that dialysis treatment can give very good results also in elderly patients. So, it is suggested that the economic and structural difficulties of dialysis Units must not influence the nephrologist's choice towards elderly patients.