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PubMed2003

A randomized controlled trial of haemoglobin normalization with epoetin alfa in pre-dialysis and dialysis patients.

BACKGROUND: Partial correction of renal anaemia with erythropoietin improves quality of life (QoL). We aimed to examine if normalization of haemoglobin with epoetin alfa in pre-dialysis and dialysis patients further improves QoL and is safe. METHODS: 416 Scandinavian patients with renal anaemia [pre-dialysis, haemodialysis (HD) and peritoneal dialysis patients] were randomized to reach a normal haemoglobin of 135-160 g/l (n=216) or a subnormal haemoglobin of 90-120 g/l (n=200) with or without epoetin alfa. Study duration was 48-76 weeks. QoL was measured using Kidney Disease Questionnaires in 253 Swedish dialysis patients. Safety was examined in all patients. RESULTS: QoL improved, measured as a decrease in physical symptoms (P=0.02), fatigue (P=0.05), depression (P=0.01) and frustration (P=0.05) in the Swedish dialysis patients when haemoglobin was normalized. In pre-dialysis patients, diastolic blood pressure was higher in the normal compared with the subnormal haemoglobin group after 48 weeks. However, the progression rate of chronic renal failure was comparable. In the normal haemoglobin group (N-Hb), 51% had at least one serious adverse event compared with 49% in the subnormal haemoglobin group (S-Hb) (P=0.32). The incidence of thrombovascular events and vascular access thrombosis in HD patients did not differ. The mortality rate was 13.4% in the N-Hb group and 13.5% in the S-Hb group (P=0.98). Mortality decreased with increasing mean haemoglobin in both groups. CONCLUSIONS: Normalization of haemoglobin improved QoL in the subgroup of dialysis patients, appears to be safe and can be considered in many patients with end-stage renal disease.

Aged↗
PubMedDate not supplied

Nutritional markers during peritoneal dialysis: data from the 1998 Peritoneal Dialysis Core Indicators Study.

OBJECTIVE: This analysis explores the nutritional status of adult U.S. peritoneal dialysis (PD) patients. DESIGN: The Peritoneal Dialysis Core Indicators Study is a prospective cross-sectional prevalence survey describing the care provided to a random sample of adult U.S. PD patients. METHODS AND POPULATION: Prevalence data were collected from a national random sample of 1381 adult PD patients participating in the United States End Stage Renal Disease (ESRD) program. RESULTS: The median age of these patients was 55 years, 61% were Caucasian; the leading cause of ESRD was diabetes mellitus. Age, sex, size, peritoneal permeability, dialysis adequacy, and nutritional indices did not differ between patients on continuous ambulatory PD and patients on automated PD. The dialysis prescriptions employed achieved mean weekly Kt/V urea (wKt/V) and creatinine clearance (wCCr) values of 2.22 +/- 0.57 and 67.8 +/- 22.5 L/1.73 m2/week, respectively. The PD patients were large, with a mean body weight of 77 +/- 21 kg and body mass index (BMI) of 27 +/- 8.6 kg/m2. The mean serum albumin of these patients was 3.5 +/- 0.51 g/dL, and 43% of values fell below the National Kidney Foundation Dialysis Outcomes Quality Initiative's desired range. The PD patients had a normalized protein equivalent of nitrogen appearance (nPNA) of 1.0 +/- 0.57 g/kg/day, a normalized creatinine appearance rate (nCAR) of 17 +/- 7.3 mg/kg/day, and an estimated lean body mass (%LBM) of 62% +/- 18% of body weight. Serum albumin correlated positively with patient size, nCAR, and nPNA, but negatively with age, the presence of diabetes mellitus, female gender, erythropoietin dose, the creatinine dialysate-to-plasma ratio results of peritoneal equilibration testing, and the dialysis portion of the wCCr. The duration of ESRD experience correlated negatively with both serum albumin and patient size, although these relationships were complex. CONCLUSION: Peritoneal dialysis patients generally have marginal serum albumin levels, a finding incongruent with alternative measures of nutritional status, such as weight, BMI, and creatinine generation. Serum albumin is reduced in patients with high peritoneal permeability (i.e., rapid transporters) and, because these patients generally have higher than average wCCr values, serum albumin is inversely correlated with the dialysis component of the wCCr. The presumptive nutritional indicators (BMI, %LBM, nPNA, and serum albumin) provide disparate estimates, varying from 10% to 50% for the prevalence of nutritionally stressed PD patients.

Adult↗
PubMed2002

[Effect of a dialysis solution with icodextrin on ultrafiltration and selected metabolic parameters in patients treated with peritoneal dialysis].

BACKGROUND: To date, peritoneal dialysis has been performed almost exclusively using dialysis solutions containing glucose as the osmotic agent. Use of these solutions is fraught with problems regarding adequate fluid removal from the body and is also associated with undesirable metabolic effects; hence the search for alternative osmotic agents. A dialysis solution with the glucose polymer icodextrin generates ultrafiltration on the principle of colloidal osmosis. The aim of the study was to establish the effect of icodextrin-base dialysis solution on the magnitude of ultrafiltration and evaluate selected metabolic parameters of patients treated by ambulatory peritoneal dialysis. METHODS AND RESULTS: A total of 9 patients whose glucose-based solution was replaced by an icodextrin-based solution during the night-time exchange were evaluated. A control group of 9 patients used glucose-solution during all exchanges. Night-time bag ultrafiltration, blood pressure, and the serum levels of lipids, insulin, leptin, maltose, and amylase were determined before icodextrin administration (time 0), at one-month intervals (time 1, 2, 3), and one month after study completion (time 4). In icodextrin-treated patients, ultrafiltration rose from 246.5 +/- 60.5 ml (mean +/- SEM) at time 0 to 593.1 +/- 87.4 ml; p < 0.01, at time 1, to 547 +/- 67 ml; p < 0.05, at time 2, and to 586.7 +/- 58.8 ml; p < 0.01, at time 3, the icodextrin administration led to a rise in maltose from 0.02 +/- 0.01 g/l at time 0 to 0.1 +/- 0.1 g/l; p < 0.01, at time 1, to 1.0 +/- 0.09 g/l; p < 0.01, at time 2, and to 1.1 +/- 0.09 g/l; p < 0.01, at time 3, with a fall to zero values at time 4 (NS). Icodextrin administration was followed by a decrease in leptinemia from 34.6 +/- 17.2 ng/ml at time 0 to 21.7 +/- 8.9 ng/ml; p < 0.05, at time 1, to 21.4 +/- 9.5 ng/ml; p < 0.05, at time 2, and to 15.9 +/- 24.1 ng/ml; p < 0.05 at time 4. Insulin and lipid levels were not affected. There was no change in the above parameters in the control group. Icodextrin-treated patients reduced their antihypertensive medication, but not statistically significantly. CONCLUSION: Icodextrin administration significantly increase ultrafiltration thus providing for effective control of hydration status without the need for high-level glucose-based dialysis solutions. The use of a glucose polymer-based dialysis solution is associated with a significant yet reversible rise in serum maltose. The decrease in leptin may signal a reduction in body weight after replacing glucose in dialysis solutions with icodextrin, or enhanced rates of leptin elimination as a result of ultrafiltration-induced convective transport.

Adult↗
PubMedDate not supplied

[Early or late referral patterns of 1137 patients starting dialysis in 15 Italian dialysis centres].

INTRODUCTION: Data on referral patterns of patients with end-stage renal failure starting renal replacement therapy were collected. The participating centres used the PFA Patients Flow Analysis (R) software programme, a Baxter tool designed to help improve data collection on dialysis patients from their first visit to the centre to the start of renal replacement therapy. METHODS: Data were collected on 1137 patients from 15 dialysis centres, mainly in northern Italy, with the aim of describing a) their referral modalities; b) their eligibility to renal replacement treatments; c) the number of early and late referrals utilising a permanent PD (Peritoneal Dialysis) or HD (Haemodialysis) access at the first treatment. RESULTS: Early Referrals (ERs) (54%) are comparable in terms of their main characteristics (sex and age) to Late Referrals (LRs) but they have wider access to a PD or to the opportunity of choosing their dialysis modality. The majority (89%) of all ERs, have a permanent access at the first dialysis treatment and a larger number (44%) have a PD as permanent dialysis treatment. Centres with structured pre-dialysis educational programmes achieve better outcomes: 66.3% patients vs. 48.2% without enhanced education start the dialysis treatment with a permanent access and more patients (40% vs. 22%) receive a permanent PD. CONCLUSIONS: Comparing centres with and without timely structured educational interventions seems to confirm the effectiveness of such education on the outcomes of ESRF patients.

Aged↗
PubMed2004

Dialysis dose and nutrition in Japanese peritoneal dialysis patients.

In the present study, we tried to determine the relationship between dialysis dose and nutrition in PD patients. We enrolled 100 Japanese outpatients, including 11 diabetic patients, who were on continuous ambulatory peritoneal dialysis [CAPD (n = 74)] and automated peritoneal dialysis [APD (n = 26)] at 49 local hospitals. In all patients, a peritoneal function test (PET) was performed using the PD NAVI software (JMS, Hiroshima, Japan). The PD NAVI software measured parameters of nutrition and dialysis dose; percentage creatinine generation rate (%CGR); percentage lean body mass normalized to body weight (%LBM); normalized protein nitrogen appearance (nPNA); total fluid removal (TFR), including urine; weekly total Kt/V; and creatinine clearance (CCr). The %CGR correlated linearly with %LBM and nPNA, parameters of the nutrition status of the patients. The %CGR also showed a significant linear correlation with Kt/V, CCr, and TFR. Patients with a %CGR below 100% (the "low group") numbered 37 (32 men, 5 women). The CCr and TFR values in that group were lower than the CCr and TFR values in the other patients (the "high group"). Conclusively, the dialysis dose did not reach the solute clearance values proposed by the National Kidney Foundation Dialysis Outcomes Quality Initiative. That finding may be the result of prescribing and monitoring dialysis therapy based on the PET The %CGR by PD NAVI may become an important index for clinical evaluation of PD dose and optimal dialysis prescription.

Biological Transport↗
PubMed1994

Careful patient selection and dialysis prescription are required for effective nightly intermittent peritoneal dialysis.

OBJECTIVE: To evaluate the adequacy of dialysis in patients on nighttime intermittent peritoneal dialysis (NIPD). DESIGN: Retrospective review of prospectively collected data. PATIENTS: Seven patients on NIPD. MEASUREMENTS: The fast peritoneal equilibration test (PET) was used to determine peritoneal membrane permeability for small solutes. Adequacy of dialysis measured by 24-hour collections of dialysate and urine for weekly KT/V and creatinine clearance in liters/week/1.73 m2 was assessed in patients with (n = 3) and without (n = 4) residual renal function and evaluated in concert with the patient's clinical status. Outcome for each patient was also noted. RESULTS: Five of the patients had a high-average dialysate/serum creatinine by PET ( > 0.66). Despite a weekly KT/V of 1.7 or more, four of the seven patients on NIPD were uremic and either transferred to hemodialysis or continuous cycling peritoneal dialysis (CCPD). A fifth patient had a KT/V of 1.4 and was also uremic on NIPD. The patient who was clinically well and continued on NIPD had significant residual renal function. CONCLUSIONS: NIPD should be restricted to patients with high-average dialysate/serum creatinine as determined by PET and residual renal function or those with high dialysate/serum creatinine. Extended dialysis time and large volumes of dialysate are required for successful NIPD in patients without residual renal function. Accepted parameters of dialysis adequacy used for patients on continuous peritoneal dialysis are not appropriate for intermittent forms of peritoneal dialysis.

Creatinine↗
PubMed2002

Impact of years of dialysis therapy on mortality risk and the characteristics of longer term dialysis survivors.

With improving survival and a decreasing probability of receiving a transplant, patients with end-stage renal disease (ESRD) are more likely to remain on hemodialysis therapy for more years than in the past. This study evaluates the effect of years on dialysis (vintage) on relative risk (RR) for death with and without adjustment for comorbidities and treatment factors. It also compares characteristics of patients on hemodialysis therapy for 7 years or longer with those on hemodialysis therapy for 1 to 7 years. Data were combined from two special US Renal Data System studies, the Case Mix Adequacy Study and Waves 1, 3, and 4 of the Dialysis Mortality and Morbidity Study. Excluding the first year of dialysis, 12,687 patients were studied during a 2-year follow-up, censoring at transplantation or loss to follow-up. Unadjusted analysis (vintage 1 to < 2 years as referent) showed that the risk for death remained nearly the same until the end of year 7 of dialysis therapy, after which the risk decreased significantly. However, with adjustment for demographics, comorbidities, and treatment factors, vintage was significantly associated with increased mortality risk during years 2 to less than 8 (RR = 1.12 to 1.30; P < 0.05). Vintage was independently associated with increased adjusted mortality among patients with and without diabetes until approximately 6 to less than 8 years of dialysis therapy. Patients on dialysis therapy for 7 years or longer were significantly (P < 0.05) more likely to be women, younger, and have lower phosphorus levels, higher hematocrits, and higher delivered dialysis doses. We conclude that adjusted mortality risk does not decrease with years on dialysis therapy, and modifiable factors deserve greater attention to improve survival among patients with ESRD with and without diabetes treated by hemodialysis.

Diabetes Complications↗
PubMed1998

A multicenter comparison of dialysis membranes in the treatment of acute renal failure requiring dialysis.

The mortality of patients with acute renal failure (ARF) remains high, and in several large studies approaches 60%. This mortality is particularly high in patients with ARF who require dialysis and has not changed substantially over several years, despite the introduction of major advances in monitoring and treatment. Increasing prevalence of comorbidities has been suggested as the major factor in this persistently high mortality. This study investigates the potential role of the dialysis membrane on patient outcome in a prospective multicenter study of 153 patients with ARF requiring dialysis. The membrane assignment was made in alternating order and was limited to membranes with low complement activation (Biocompatible [BCM]) and cellulosic, high complement activation (Bioincompatible [BICM]). Both types of membranes were low-flux membranes. Patients were dialyzed with the assigned membrane until recovery, discharge from hospital, or death. The severity of illness of each patient was assessed using the APACHE II score at the time of initiation of dialysis. A logistic regression analysis was used to adjust for the APACHE II score. The results of the study showed a statistically significant difference in survival (57% in patients on BCM, 46% in patients on BICM; P = 0.03) and in recovery of renal function (64% in patients on BICM and 43% in patients on BICM; P = 0.001). These differences were particularly marked in the patients who were nonoliguric (>400 ml/d of urine output) at initiation of the study. In the subset of patients who were nonoliguric at the start of dialysis, a larger fraction (70%) became oliguric after initiating dialysis on a BICM membrane, in contrast to 44% who were initiated on a BCM membrane (P = 0.03). It is concluded that the biocompatibility of the dialysis membrane plays a role in the outcome of patients with ARF, particularly those who are nonoliguric at the time of initiation of dialysis.

APACHE↗
PubMedDate not supplied

The impact of increasing the daytime dialysis exchange frequency on peritoneal dialysis adequacy and nutritional status of Chinese anuric patients.

OBJECTIVE: To study the effect of increasing the daytime dialysis exchange frequency on dialysis adequacy and nutritional status of Chinese anuric patients. SETTING: University teaching hospital. PATIENT: 100 anuric patients on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: 50 patients had one additional daytime 2-L exchange (intervention group); the dialysis regimen remained unchanged in the other 50 patients (control group). OUTCOME: Dialysis adequacy [Kt/V, weekly creatinine clearance (wCCr), and net ultrafiltration (UF)] and nutritional status [serum albumin, dietary protein intake, represented by normalized protein nitrogen appearance (nPNA), and percent lean body mass (%LBM)] were measured at 0 and 6 months. RESULTS: Baseline dialysis adequacy and nutritional indices were comparable between the two groups. In the control group, all parameters remained stable at month 6. In the intervention group, there were significant increases in UF, Kt/V, wCCr, nPNA, and %LBM from months 0 to 6. The improvement in nPNA was affected by daily exchange volume. In 30 patients, the number of exchanges was increased from 3 to 4 per day; their Kt/V and nPNA rose significantly from month 0 to month 6. In the other 20 patients, the number of exchanges was increased from 4 to 5 per day; there was a significant increase in Kt/V but nPNA remained static. The change in nPNA correlated inversely with Kt/V at month 0 (Pearson's r = -0.352, p = 0.012). Multivariate analysis with a general linear model showed that age, Kt/V at month 0, and 3 dialysis exchanges per day at month 0 (versus 4 exchanges) were independent predictors of the change in nPNA. CONCLUSIONS: Increasing the number of peritoneal dialysis exchanges effectively increased Kt/V in Chinese anuric CAPD patients. However, the improvement in nPNA correlated inversely with baseline Kt/V. Although increasing the number of exchanges from 3 to 4 per day improved nPNA, increasing the number of daily exchanges beyond 4 may not improve nPNA further.

Anuria↗
PubMed2004

Effects of different dialysis membranes on serum concentrations of epoetin alfa, darbepoetin alfa, enoxaparin, and iron sucrose during dialysis.

BACKGROUND: Numerous substances are administered during dialysis for anticoagulation and the treatment of anemia and iron deficiency. The availability of current dialysis membranes is diverse, but assessment of the effects of different membranes on these routinely administered substances is lacking. This prospective study appraises specific effects of 7 dialysis membranes (4 low-flux membranes, 3 high-flux membranes) on the handling of 4 commonly administered agents (epoetin alfa, darbepoetin alfa, enoxaparin, and iron sucrose) during dialysis. METHODS: Using a different membrane sequentially, 6 stable hemodialysis patients were treated with epoetin alfa, enoxaparin, and iron sucrose, and 6 patients with darbepoetin alfa. Serum concentrations (predialyzer and postdialyzer) of each substance were assessed after administration and after 4 hours of dialysis (predialyzer). RESULTS: Overall, use of low-flux membranes resulted in similar serum concentrations for all compounds. However, use of high-flux membranes showed reduced antifactor Xa levels immediately (predialyzer, P = 0.028; postdialyzer, P = 0.027) and 4 hours after (P = 0.001) administration of enoxaparin compared with low-flux membranes. Variable changes in darbepoetin concentrations also were found between the high-flux membranes during dialysis (P = 0.009). Although peak serum concentrations of all compounds were inversely proportional to body weight, the percentage of change during dialysis was not related to dosage or body weight. CONCLUSION: High-flux membranes may require greater doses of enoxaparin to ensure adequate anticoagulation during dialysis and may be associated with variable changes in darbepoetin concentrations. For other compounds, no noteworthy difference among membranes was defined.

Adult↗
PubMed2004

[Nutrition and dialysis: how to keep adequate nutrition in dialysis?].

Malnutrition is frequent in dialysis patients and it increases the mortality risk in this setting. There are many causes of malnutrition including protein metabolism impairment, amino acid and nutrient losses in dialysate, dialysis-induced muscle catabolism, metabolic acidosis, increased energy expenditure, resistance to anabolic hormones, comorbidities, oxidant stress and inflammation whose mechanisms are not identified well. Inflammation and malnutrition are associated with vascular complications frequently observed in dialysis patients. Daily nutrient needs have been established from nitrogen balance studies. The recommended intakes are 1,2 g/ kg/day for proteins, and 35 Kcal/kg/day for energy. Food intake in dialysis patients remain far below these recommendations in most of the studies, mainly because of anorexia caused by inflammation and the uremic state. Dialysis dose or frequency increase food intake. Evaluation of the nutritional status relies on biological parameters and anthropometrics, with food intake records. Nutritional scores, established from these data, are well correlated with patient outcomes. Malnutrition treatment includes counselling, and suppression of all inflammation sources. Appetite stimulants have been seldom used in this setting. Oral supplements may be efficient Intradialytic parenteral nutrition in hemodialysis patients and amino acid-enriched dialysate in peritoneal dialysis improve nutritional parameters of malnourished patients but their efficiency to improve patient survival is questioned. Adequate nutrition is an important challenge for dialysis patient outcome. Nutritional status must be regularly assessed and treated if necessary. Close collaboration between dialysis and dietetic staffs remains essential to handle this challenge.

Humans↗
PubMed1987

The influence of dialysis fluid composition on dialysis tolerance.

To evaluate the role of bicarbonate loss through the dialyser and acetate flux to the patient in the development of symptoms during acetate dialysis, bicarbonate loss during acetate dialysis was prevented by using a combination of acetate and bicarbonate in the dialysate. Seven uraemic patients were treated for 4 months with acetate dialysis and, successively, for a similar period of time with bicarbonate, and a combination of acetate and bicarbonate dialysis. Blood-pressure drop and the incidence of hypotension and symptomatic episodes were similar in bicarbonate and combination dialysis, and significantly lower than in acetate dialysis. Serum acetate concentrations were similar during acetate and combination dialysis. These findings indicate that bicarbonate loss rather than the presence of acetate was responsible for the patients' intolerance to acetate dialysis.

Acetates↗
PubMed1999

Hemodialysis together with peritoneal dialysis is one of the simplest ways to maintain adequacy in continuous ambulatory peritoneal dialysis.

When long-term peritoneal dialysis (PD) is performed without change in the dialysis prescription, uremic symptoms appear owing to insufficient dialysis dose. In such cases, an increase in dialysate volume is required, but this increase is difficult to obtain in all patients owing to limitations in abdominal volume, lifestyle, or body weight. A combination of PD and hemodialysis (HD) is the simplest method of overcoming these limitations. Combination therapy--HD once per week for 4 hours and PD 6 days per week--was performed in our patients. The total weekly dialysis dose (urea) was calculated as follows: to convert the dialysis dose by HD to that of continuous treatment, the equivalent renal urea clearance (EKR) was calculated and added to the dialysis dose by PD. Combination therapy was performed in 12 patients. The reasons for the combination therapy included ultrafiltration (UF) loss in 2 patients, uremic symptoms in 3 patients, poor fluid management in 5 patients, umbilical hernia in 1 patient, and hydrothorax in 1 patient. Total Kt/V per week was increased from 1.61 +/- 0.19 to 2.05 +/- 0.25 in these patients. In the 2 patients with UF loss, weight control became easier after the combination therapy was started, and this control was possible with hypotonic dialysate alone. In patients with uremic symptoms, the symptoms improved; furthermore, dermal pigmentation improved in these patients. In summary, the dialysis dose was increased and body fluids became controllable after inducing combination therapy, resulting in improvement uremic symptoms and increased quality of life.

Adult↗
PubMedDate not supplied

Cost of home dialysis versus institutional dialysis.

An actual cost analysis in the summer of 1975 showed that under the most costly of circumstances possible, home dialysis is always much less costly than institutional dialysis. During the first year of dialysis, when a patient must go through the expensive part of being trained for home dialysis in the center and of having the equipment installed, home dialysis even then is between $5,000 and $10,000 less costly than center dialysis. In subsequent years, after the initial outlay, home dialysis will be between $8,000 and $13,000 less costly than center dialysis.

Community Health Centers↗
PubMed1983

Medicare program; end-stage renal disease program; prospective reimbursement for dialysis services and approval of special purpose renal dialysis facilities--HCFA. Final rule.

These regulations change the reimbursement system by which Medicare pays for outpatient maintenance dialysis and related physician and laboratory services. These changes establish a prospective method of payment for maintenance dialysis, whether furnished at home or in a hospital-based or independent dialysis facility, and revise other aspects of the reimbursement system to encourage home dialysis and provide incentives for economy and efficiency in furnishing these services. These amendments implement section 2145 of the Omnibus Budget Reconciliation Act of 1981. We expect that these changes will improve our administration of the end-stage renal disease program and enable us to control the rapidly growing costs of furnishing dialysis. The controls on quality of care that have been in effect since the beginning of the program will continue to apply. These regulations will also ensure access to care by providing for adequate reimbursement to isolated, essential facilities, where patients have no alternative sources of dialysis care. These regulations also provide for time-limited approval for Medicare participation of special purpose renal dialysis facilities. As a general rule we have not approved facilities such as transient or mobile units set up for emergency purposes or to serve vacationing dialysis patients in State parks and children's camps. This change in regulations will remove this limitation.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1996

The impact of diabetes on patients' survival in dialysis patients with non-diabetic renal disease and in patients who develop diabetes during chronic dialysis.

BACKGROUND: It is well known that dialysis patients with diabetic nephropathy have a poor prognosis, but data concerning the survival of dialysis patients with diabetes plus a non-diabetic primary nephropathy or the survival of patients who develop diabetes after the start of regular dialysis are scarce. AIM AND METHODS: We reviewed the survival of two cohorts of dialysis patients in whom diabetes mellitus was associated with non-diabetic primary nephropathy. In the first cohort (18 patients with a primary diagnosis of APKD) diabetes mellitus precede hyperazotaemia, whilst the second cohort of 34 patients developed diabetes after the start of regular dialysis. We compared the survival of each group of patients to the survival of a group of dialysis patients with a primary diagnosis of diabetic nephropathy, and to the survival of each control group of non-diabetic dialysis patients. Within each case series, groups were similar according to age at start of RRT, and place of treatment. All patients were selected among those alive in treatment at 31 December 1986 and were followed up to 31 December 1991. RESULTS: In both case series the survival of patients with diabetes was similar irrespective of the primary diagnosis (Lee-Desu statistics: first cohort P=0.43; second cohort, P=0.08). Moreover, the survival of patients either with diabetic nephropathy or with diabetes in association with non-diabetic primary nephropathy was significantly worse compared to the survival of the non-diabetic patients (Lee-Desu statistics: first case series P=0.02 and P<0.01; second case series P<0.05 and P<0.01). Logistic regression showed that survival was negatively associated to diabetes and age but not to sex, duration of diabetes and diagnosis of diabetic nephropathy. CONCLUSIONS: Our limited data show that the survival of diabetic patients on regular dialysis is poor, irrespective of the primary cause of renal failure and of the duration of diabetes. These data need confirmation and further study.

Cohort Studies↗
PubMed1998

Long-term effects of intermittent oral alphacalcidol, calcium carbonate and low-calcium dialysis (1.25 mmol L-1) on secondary hyperparathyroidism in patients on continuous ambulatory peritoneal dialysis.

OBJECTIVES: (i) To examine the effect of alphacalcidol [1 alpha(OH)D3] given as an oral dose twice weekly in combination with CaCO3 and low-calcium dialysis (1.25 mmol L-1) on the secondary hyperparathyroidism in continuous ambulatory peritoneal dialysis (CAPD). (ii) To examine the changes in peritoneal mass transfer for calcium, phosphorus, magnesium, lactate, creatinine, urea, glucose, pH and albumin after shift to low-calcium dialysis solution. DESIGN: An open study in patients on CAPD. SETTING: Renal division, Rigshospitalet, Copenhagen. SUBJECTS: Thirty-nine patients were included and completed 12 weeks of treatment. Thirty of the patients completed 52 weeks of treatment. A peritoneal equilibrium test (PET) was performed in seven patients. INTERVENTIONS: Following two sets of blood samples obtained as basal values the calcium concentration was reduced in the dialysis fluid from 1.75 mmol L-1 to 1.25 mmol L-1. Increasing doses of oral 1 alpha(OH)D3 were then administered under careful control of p-ionized calcium (p-Ca2+) and p-inorganic phosphate (p-P1). Blood samples were obtained every 2-4 weeks for 52 weeks. PET was performed using standard dialysis fluid and 1 week later using low-calcium dialysis fluid after a preceding overnight dwell. Two litres of glucose 22.7 mg mL-1 were used. MAIN OUTCOME MEASURES: Intact parathyroid hormone (PTH), p-Ca2+, p-P1, doses of CaCO3, doses of 1 alpha(OH)D3, peritoneal mass transfer for calcium, inorganic phosphate, magnesium, lactate, creatinine, urea, glucose and albumin. RESULTS: Thirty nine patients with initial PTH values 144 +/- 26 pg mL-1 were followed for 12 weeks and 30 patients for 52 weeks. A negative calcium balance was induced after shifting to low-calcium dialysis fluid. After 2 weeks of treatment a significant increase of PTH by approximately 60% and a small but significant decrease of p-Ca2+ was observed. After 12 weeks of treatment with increasing doses of 1 alpha(OH)D3 and CaCO3, PTH was again reduced to levels not significantly different from the initial values. After 52 weeks of treatment no deterioration of the secondary hyperparathyroidism was seen. CONCLUSIONS: A calcium concentration of 1.25 mmol L-1 in the CAPD dialysate made it possible to reduce the amount of aluminium-containing phosphate binder, to increase the doses of CaCO3 and to use pulse oral 1 alpha(OH)D3 without causing severe hyper-calcaemia in the patients. After a short elevation of PTH, the PTH levels remained at normal or near normal levels and the long-term results clearly demonstrated that an aggravation of the secondary hyperparathyroidism could be inhibited.

Albumins↗
PubMed1999

Physical symptoms and quality of life in patients on chronic dialysis: results of The Netherlands Cooperative Study on Adequacy of Dialysis (NECOSAD)

BACKGROUND: So far, little attention has been paid to the value of dialysis adequacy for patients' quality of life (QL). Therefore we studied the impact of demographic, clinical, and dialysis characteristics on physical symptoms and perceived QL. METHODS: The study population consisted of 120 incident chronic haemodialysis (HD) and 106 peritoneal dialysis (PD) patients, starting dialysis treatment in 13 Dutch centres. Data were collected 3 months after the start of dialysis. Nine physical symptoms were assessed with a self-administered questionnaire. Patient's self-assessment of QL was measured with the 36-item MOS Short Form (SF-36). RESULTS: The most common symptoms in HD and PD were fatigue (respectively 82 and 87%) and itching (73 and 68%). In HD only a medium to high comorbidity--age risk index was associated with greater symptom burden. In PD also a lower percentage lean body mass, a lower rGFR, and past episodes of underhydration were associated with greater symptom burden. The explained variance by these variables was only 12% in HD and 21% in PD. However, greater symptom burden explained a substantial additional amount of impaired physical and mental QL on top of demographics and clinical status. Dialysis variables were associated neither with symptoms nor with QL. CONCLUSION: Symptom burden can be explained to a limited extent by demographic and clinical variables and not by dialysis characteristics. Addition of symptom burden to the other variables makes it possible to explain one-third of perceived QL. This underlines the importance of symptom reduction in order to improve patient's QL.

Adult↗