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Biomedical subjects

J Bernardini

Publications and source records attributed to J Bernardini.

At least 19 recordsLinked to original sources
PubMed2006

Prevention of infectious complications in peritoneal dialysis: best demonstrated practices.

Peritoneal dialysis (PD) related infections continue to be a serious complication for PD patients. Peritonitis can be associated with pain, hospitalization and catheter loss as well as a risk of death. Peritonitis risk is not evenly spread across the PD population or programs. Very low rates of peritonitis in a program are possible if close attention is paid to the causes of peritonitis and protocols implemented to reduce the risk of infection. Protocols to decrease infection risk in PD patients include proper catheter placement, exit-site care that includes Staphylococcus aureus prophylaxis, careful training of patients with periodic retraining, treatment of contamination, and prevention of procedure-related and fungal peritonitis. Extensive data have been published on the use of antibiotic prophylaxis to prevent exit site infections. There are fewer data on training methods of patients to prevent infection risk. Quality improvement programs with continuous monitoring of infections, both of the catheter exit site and peritonitis, are important to decrease the PD related infections in PD programs. Continuous review of every episode of infection to determine the root cause of the event should be routine in PD programs. Further research is needed examining approaches to decrease infection risk.

Benchmarking↗
PubMed2001

Charlson comorbidity index as a predictor of outcomes in incident peritoneal dialysis patients.

A previous study at our center used the Charlson Comorbidity Index (CCI) (an index of comorbidity that includes age) to predict outcomes in a mixed group of incident and prevalent dialysis patients. The purpose of this study was to examine the usefulness of the CCI as a predictor in incident peritoneal dialysis (PD) patients and to examine whether it was a better predictor than simply the number of comorbid conditions or other known predictors, such as age, albumin level, diabetes, and cardiovascular disease. Since 1990, we have collected prospectively comorbidity data at the start of PD. All patients with known comorbidity and serum albumin and who did not have a prior history of hemodialysis or transplant were included (n = 268). Time at risk began at day 1 of PD training. Cox proportional hazards best subset selection was used to screen models to predict patient survival. Candidate models were analyzed further for proportionality and other model assumptions. Univariate analysis showed that significant predictors of mortality were CCI (chi-square = 43.3, P < 0.0001), age (chi-square = 23.7, P < 0.0001), cardiac disease (chi-square = 19.9, P <0.0001), number of comorbid conditions (chi-square = 15.6, P < 0.0001), serum albumin at the start of dialysis (chi-square = 15.3, P = 0.0001), and diabetes (chi-square = 4, P < 0.05). In multivariate analysis, CCI alone was the best predictor. The addition of serum albumin did not improve the model significantly (chi-square = 51.86 versus 49.34). For every increase of 1 in the CCI score, the relative risk of death was 1.54 (95% confidence interval, 1.36 to 1.74). CCI alone scored at the start of PD is a strong predictor of patient survival in incident end-stage renal disease patients on PD. This simple-to-calculate index would be useful to adjust for confounding in future studies and in the adjustment of case mix if Medicare moves to a capitated payment system.

Analysis of Variance↗
PubMed2001

The outcome of peritonitis in patients on automated peritoneal dialysis.

We reviewed all peritonitis over the last decade to compare patient outcomes on automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). There were 327 episodes of peritonitis in 198 patients during this period. The rates were 0.57 per patient-year and 0.55 per patient-year on APD and CAPD respectively. For 52% of the episodes, the patients were admitted and managed with a mixture of CAPD and APD, so that no further analysis of outcomes was performed. For 48% (158) of the episodes, the patients were treated as outpatients and remained on their existing modality: 49 on APD and 100 on CAPD (9 catheter-related peritonitis excluded). In the APD group, 5 catheters were eventually removed for recurrent or refractory peritonitis. One other patient died in conjunction with peritonitis. Therefore, the adverse outcome was 12% on APD (6/49 episodes). In the CAPD group, 5 catheters were removed for refractory or relapsing peritonitis (including 1 for peritonitis with a leak). One other patient with fungal peritonitis died. Therefore, the adverse outcome on CAPD was 6% (6/100 episodes), which is not statistically different from the 12% on APD (p = 0.21). In summary, the incidence of peritonitis was similar on APD and CAPD, with one half the patients in each group requiring admission. In peritonitis treated on an outpatient basis, failure was twice as high with continuation of APD as compared with continuation of CAPD, but the difference was nonsignificant. Further studies on managing peritonitis in patients on APD are needed.

Adolescent↗
PubMed2000

Pattern of noncompliance with dialysis exchanges in peritoneal dialysis patients.

The purpose of the study is to evaluate the pattern of noncompliance in peritoneal dialysis (PD) patients using home visit supply inventories. Ninety-two patients were enrolled at the start of dialysis. Noncompliance, defined as performance of less than 90% of prescribed exchanges, was found in 30% of patients during the first 6 months of PD. Patients who were noncompliant with prescribed exchanges at the start of PD had greater rates of death (P = 0.03), transfer to hemodialysis secondary to uremia (P < 0.05), hospitalization (P < 0.001), and days hospitalized (P < 0.001) compared with compliant patients. Delivered Kt/V was 18% less in noncompliant compared with compliant patients (2.1 versus 2.57; P = 0.007). Serial evaluations of compliance in 53 patients showed that 72% were consistently compliant, 2% were consistently noncompliant, 15% were noncompliant at the beginning of PD but became compliant at follow-up, and 11% were intermittently noncompliant. The likelihood of future compliance in a patient compliant at the first home visit was 88%. Patients who were independent with their dialysis exchanges were more likely to be noncompliant (27%) than patients dependent on someone else to perform their dialysis (8%; P = 0.05). Serial 24 hour creatinine excretion was not a useful method to determine compliance. We recommend a home visit during the first 6 months of PD to determine compliance. Those found compliant probably do not need repeated evaluations, whereas noncompliant patients should be reevaluated in a few months. Involving another person in the dialysis might relieve some of the burden on patients who may be initially unable to cope with home dialysis. Identification of noncompliant patients and awareness of risk factors should reduce noncompliance and improve patient outcomes.

Creatinine↗
PubMed2000

A trial of thyroxine in acute renal failure.

UNLABELLED: A trial of thyroxine in acute renal failure. BACKGROUND: Acute renal failure (ARF) remains a serious medical problem with a high mortality rate. Efforts to shorten the course of ARF might reduce this mortality. Since thyroxine has been shown in experimental models to shorten the course of ARF, we designed a trial to determine if a defined course of thyroxine would alter the course or change the mortality of clinical ARF. METHODS: A prospective, randomized, placebo-controlled, double-blind trial of thyroxine was carried out in patients with ARF. End points were the percentage requiring dialysis, the percentage recovering renal function, time to recovery, and mortality. RESULTS: Fifty-nine patients were randomized to receive either thyroxine or placebo. The groups were well matched in terms of basal and entry creatinines, age, sex, APACHE II scores at entry, and percentage oliguric. Baseline thyroid functions, including T3, T4, rT3, and thyroid stimulating hormone (TSH) levels, were equal between the two groups and typical of patients with euthyroid sick syndrome. Thyroxine resulted in a progressive and sustained suppression of TSH levels in the treated group, but had no effect on any measure of ARF severity. Mortality was higher in the thyroxine group than the control group (43 vs. 13%) and correlated with suppression of TSH. CONCLUSIONS: In contrast to the beneficial effects seen in experimental ARF, thyroxine has no effect on the course of clinical ARF and could have a negative effect on outcome through prolonged suppression of TSH. Critically ill euthyroid sick patients should not be replaced with thyroid hormone.

APACHE↗
PubMed2000

Patients on chronic peritoneal dialysis for ten years or more in North America.

Thirty-six patients on peritoneal dialysis (PD) for more than ten years in six North American centers were analyzed retrospectively. In the six centers, the percentage of patients surviving for more than ten years varied between 0.8% and 7.3%. The study group included 27 females and 9 males aged 38.6 +/- 14.2 years [mean +/- standard deviation (SD)] at the start of treatment. Of the 36 patients, 28 were Caucasian. The most common cause of end-stage renal disease (ESRD), present in 12 patients, was chronic glomerulonephritis. Only 4 patients had diabetes. At the beginning of the study, 19 patients had hypertension (the most common comorbid condition); 11 had no comorbid conditions at the start. Creatinine clearance at the start was 4.12 +/- 3.5 mL per minute, and the mean duration to anuria was 51 +/- 25 months. Mean initial body weight was 55 +/- 9 kg, and mean body surface area was 1.5 +/- 0.2 m2. Serum albumin levels showed an increase from 33.8 +/- 3.6 g/L at the start of the study to 38.2 +/- 3.9 g/L at the end. Hospitalization rate was low at 0.5 +/- 0.3 admissions per patient-year, and duration of hospitalization was 4.8 +/- 3.7 days per patient-year. Peritonitis was the most common cause of hospitalization. The mean peritonitis rate was 1 episode every 52 +/- 48 patient-months. There were 36 catheter changes in 18 patients; 16 patients had a single PD catheter throughout the period of study. Autonomous hyperparathyroidism was the most common long-term complication. At the end of the study period, 11 patients were still on PD, 9 had died, 5 had been transferred to hemodialysis (HD), 1 was alive with a functioning allograft, and 1 was lost to follow-up. We conclude that patients who survive longer than ten years on PD are most likely to be young Caucasian females, small in body size, who are non diabetic, with few comorbid conditions. These long-term survivors have few hospitalizations, and their peritonitis rate is low. In this group of patients, severe autonomous hyperparathyroidism is the most common long-term complication.

Adolescent↗
PubMed2000

Compliance with subcutaneous erythropoietin in peritoneal dialysis patients.

The use of erythropoietin in dialysis patients is associated with improved quality of life and may lead to improved outcomes. Peritoneal dialysis patients are generally taught to give subcutaneous erythropoietin at home. The purpose of this study was to determine compliance with erythropoietin use in peritoneal dialysis patients. Records of patient prescriptions, refills of erythropoietin, the person administering the injection, and average hematocrit were retrospectively examined. Demographic and comorbidity data were collected prospectively on all peritoneal dialysis patients. The use of more than 90% of the prescribed dose was considered compliant. Data were available for 55 patients. The mean follow-up time was 12 months. Thirty patients (55%) were noncompliant with erythropoietin. Compliant patients were older (65.4 years vs 50 years, p = 0.01), had higher comorbidity (p = 0.01), higher average hematocrit (34% vs 31.5%, p < 0.003) and were less likely to self-administer the injection. Sex, diabetes, and compliance with dialysis exchanges were not associated with erythropoietin compliance. Using logistic regression, the only significant variable was the person administering the erythropoietin (r = 0.46, p = 0.005). Noncompliance with subcutaneous erythropoietin is a significant problem. Compliance may improve if someone other than the patient is trained to administer it.

Erythropoietin↗
PubMed1999

Tolerance of large exchange volumes by peritoneal dialysis patients.

Improving clearances on peritoneal dialysis involves either more exchanges, greater fill volume, or both. An increase in the number of exchanges is inconvenient, resulting in noncompliance. Therefore, the best option is to increase the exchange volumes; however, patients are often reluctant for fear of discomfort. We tested the tolerance of 20 patients blinded to randomly sequenced volumes of 2, 2.5, and 3 L, performed incenter by the dialysis nurse. Each patient underwent one to three exchanges with each volume. At the end of a 4-hour dwell, the patient scored discomfort and estimated the infused volume. Only one study exchange was performed each day; the rest of the time, the patient continued his or her usual prescription. Fifteen of the patients (75%) were not able to identify the exchange volumes. Four of the five patients who determined the correct exchange volume for 67% to 78% of the exchanges (P < 0.04 compared with 33% expected by chance) had a body surface area greater than 1.75 m2. Of 123 exchanges, 84% were associated with no discomfort, 10% with mild discomfort, and 6% with moderate discomfort. Patients were not more likely to have discomfort with 3-L compared with lower fill volumes. Peritoneal clearances of creatinine (6.1 v 6.6 v 7.7 mL/min/1.73 m2) and urea nitrogen (7.3 v 8.6 v 9.5 mL/min) were progressively greater with increasing exchange volumes (P < 0.001). We conclude that the majority of small as well as large patients will tolerate 2.5- and 3-L exchange volumes. If encouraged to do so, many patients could tolerate greater exchange volumes than they are presently using. Exchange volumes should be readily increased as residual renal function declines.

Adult↗
PubMed1999

Hospitalization in peritoneal dialysis patients.

Hospitalization rates are declining more rapidly for peritoneal dialysis (PD) than for hemodialysis patients. This has been postulated to be caused in part by lower peritonitis rates. However, the causes of admission have not been reexamined in the setting of declining rates. We prospectively examined our hospitalization rates, causes of admission, and impact of peritonitis on hospitalization in adult PD patients at a single center over a 4-year period. There were 274 admissions in 168 patient-years for a rate of 1.6 admissions and 13.0 hospital days per patient-year. Rates were greater for men (1.8 v 1.5; P = 0.013), patients with diabetes (2.2 v 1.4, P < 0.001), and those with a higher peritoneal equilibration test result. Creatinine clearance and sex were independent predictors in a multivariate analysis. The most common causes for admission were cardiac disease (14.6%) and peritonitis (13.5%). Peritonitis accounted for 0.21 admissions and 2.0 hospital days per patient-year. Thirty percent of the incident patients were admitted during the first 90 days of dialysis. Admissions for dehydration and glucose abnormalities were more common in the first 90 days. Overall admission rates, as well as admission rates for peritonitis, did not change over time, although hospital days per year decreased. Those admitted for peritonitis had higher peritonitis rates, more time on PD, and were more likely to be black. Eighty-one percent of the admissions for peritonitis were caused by Staphylococcus aureus, Streptococcus spp, or gram-negative/fungal peritonitis. Patients with peritonitis caused by Staphylococcus epidermidis were less likely to be admitted than patients with peritonitis caused by other organisms. To conclude, peritonitis remains a common cause of hospitalization, despite low peritonitis rates. To decrease admissions for peritonitis, attention should be focused on preventing peritonitis caused by organisms other than S epidermidis.

Female↗
PubMed1999

The relation between body size and normalized small solute clearances in continuous ambulatory peritoneal dialysis.

The normalized peritoneal clearances of small solutes depend on the ratio of their concentration in dialysate and plasma (D/P) and the drain volume (Dv) corrected for some measure of body size such as body water (V) or body surface area (BSA). The clearance formulas (D/P) x (Dv/V) and (D/ P) x (Dv/BSA) can be used to examine why large individuals tend to be underdialyzed. Large people have low normalized drain volumes (Dv/V, Dv/BSA). It is not known whether size affects the D/P ratios. The purpose of this study was to examine the relationship between normalized peritoneal clearances (Kt/Vurea, CCr per 1.73 m2 BSA) and four size indicators (weight, height, V, BSA) in 301 patients on continuous ambulatory peritoneal dialysis (four daily exchanges with 2-L exchange volume) who underwent 613 clearance studies. Highly significant (P < 0.001) nonlinear relationships were found between Kt/Vurea and weight (r2 = 0.371), height (r2 = 0.289), BSA (r2 = 0.436), and V (r2 = 0.527); and between CCr and weight (r2 = 0.178), height (r2 = 0.115), BSA (r2 = 0.199), and V (r2 = 0.151). There were also significant negative correlations between the normalized drain volumes (Dv/V and Dv/BSA) and all four indicators of body size. Raw (not normalized) peritoneal clearances and drain volumes correlated positively with size. However, D/P(urea) or D/P(creatinine) did not vary with any size indicator except for a weak association between D/P(creatinine) and V (r = 0.089, P = 0.028). This association was not confirmed when V was used to stratify subjects into quartiles, and group differences for D/P(creatinine were tested by one-way ANOVA. This study shows that the exclusive cause of the low normalized peritoneal clearances in large subjects on continuous ambulatory peritoneal dialysis is a low normalized drain volume. No evidence was found to indicate that body size influences the D/P ratio of small solutes. The portion of the variance in normalized clearance explained by size varies by size indicator and solute (urea versus creatinine).

Adult↗
PubMed1999

Small-solute clearances in diabetic subjects on continuous ambulatory peritoneal dialysis: comparison to nondiabetic subjects.

Normalized clearances for urea and creatinine were compared between 121 diabetic subjects (256 clearances) and 181 nondiabetic subjects (357 clearances) on continuous ambulatory peritoneal dialysis (CAPD) with four 2-L exchanges daily. Urea clearance was normalized by VWatson (Kt/Vur), while creatinine clearance was normalized by both VWatson (Kt/Vcr) and body surface area (Ccr). Height, weight, body water (V), and body surface area did not differ between the diabetic and the nondiabetic groups. Also, renal Kt/Vur, renal Kt/Vcr, renal Ccr, and peritoneal Kt/Vur did not differ between the groups. Weekly peritoneal Kt/Vcr (diabetic group 1.36 +/- 0.38, nondiabetic group 1.31 +/- 0.31, p = 0.048) and weekly peritoneal Ccr (diabetic group 47.6 +/- 11.0 L/1.73 m2, nondiabetic group 45.4 +/- 9.2 L/1.73 m2, p = 0.012) were both higher in diabetic subjects. The percentage of high/high-average transporters was higher in the diabetic group (64.9% vs 48.6% in nondiabetic group, p = 0.006). The following total (peritoneal + renal) weekly clearances were obtained: Kt/Vur, diabetic group 2.07 +/- 0.63, nondiabetic group 2.02 +/- 0.56, NS; Kt/Vcr, diabetic group 2.06 +/- 0.78, nondiabetic group 1.92 +/- 0.74, p = 0.026; Ccr, diabetic group 72.7 +/- 28.5 L/1.73 m2, nondiabetic group 67.2 +/- 26.4 L/1.73 m2, p = 0.013. Normalized total creatinine clearances are higher in diabetic subjects than nondiabetic subjects on the same CAPD schedule and with the same renal clearances of urea and creatinine and the same total Kt/Vur, because peritoneal creatinine clearances are higher in the diabetic subjects. This finding is caused by higher peritoneal transport in the diabetic subjects and is not an artifact caused by the normalization process.

Creatine↗
PubMed1998

Impact of acute renal failure on mortality in end-stage liver disease with or without transplantation.

BACKGROUND: Acute renal failure (ARF) is traditionally considered a poor prognostic factor in end-stage liver disease and is associated with a mortality approaching 90%. While the increased use of orthotopic liver transplantation (OLTX) has changed the outcome for patients with end-stage liver disease (ESLD), it is not clear whether this has affected the outcome of patients with ESLD and ARF. METHODS: We prospectively followed the course of ARF in 177 patients with ESLD being evaluated for OLTX. Of these patients 111 received OLTX. In-hospital mortality was compared to that of 316 ESLD patients without ARF, of these 196 received OLTX. Variables include severity of illness as assessed by APACHE II, co-morbid conditions, oliguria, need for renal replacement therapy, and etiologies of ESLD and ARF. These variables were evaluated with respect to the outcome in-hospital mortality by multiple regression analysis for patients with ARF. RESULTS: Mortality was significantly higher in oliguric versus non-oliguric patients and in patients who required renal replacement therapy. Mortality correlated strongly with the number of co-morbid conditions, especially sepsis, encephalopathy, respiratory failure, and DIC. For OLTX recipients who developed ARF, no significant difference in survival occurred whether the ARF was pre-OLTX or post-OLTX. CONCLUSION: ARF was associated with an increased mortality consistent with the known adverse prognostic effect of ARF in ESLD. However, the effect of ARF on mortality was remarkably reduced in patients who received a functioning OLTX. Since expected mortality generated from APACHE II scores was higher in the ARF groups, it is not clear that there is an additional effect of ARF beyond the physiologic derangements captured by APACHE II. ARF per se should not necessarily be a contraindication to liver transplant.

Acute Kidney Injury↗
PubMed1998

Peritoneal urea and creatinine clearances in continuous peritoneal dialysis patients with different types of peritoneal solute transport.

We studied whether anuric subjects on continuous ambulatory peritoneal dialysis (CAPD) who achieve the target Kt/V urea of 2.0 weekly will also achieve the target normalized creatinine clearance (NCCr) of 60 liter/1.73 m2 weekly, and the reasons of discrepancy between the two clearances in anuric subjects, by analyzing 476 clearance studies performed in 309 CAPD patients within 12 months of the performance of a peritoneal equilibration test (PET). On the basis of the PET, peritoneal solute transport was classified as low (37 clearance studies), low-average (199 studies), high-average (186 studies) and high (54 studies). We found that weekly values of Kt/V urea in the low transport group (LTG) was 1.74 +/- 0.51, in the low-average transport group (LATG) was 1.66 +/- 0.41, in the high-average transport group (HATG) 1.68 +/- 0.41, and in the high transport group (HTG) 1.73 +/- 0.46 (NS, variance analysis). Weekly values for NCCr, liter/1.73 m2 were: LTG, 37.8 +/- 9.0; LATG, 44.0 +/- 9.2; HATG, 49.2 +/- 10.0; HTG 56.8 +/- 13.3 (P < 0.0001). The ratios of raw (not-normalized) peritoneal creatinine clearance to peritoneal urea clearance were: LTG, 0.65 +/- 0.14; LATG, 0.76 +/- 0.09; HATG, 0.84 +/- 0.09; HTG, 0.91 +/- 0.12 (P < 0.0001). Linear regression with Kt/V urea as x and NCcr as y revealed the following results: LTG, y = 19.486 + 10.500x, r = 0.591 [if x = 2.0, y = 15.004 + confidence interval (95% CI) of y 25.3 to 55.7]; LATG, y = 15.0004 + 17.482x, r = 0.774 (if x = 2.0, y = 50.0, 95% CI of y 38.4 to 61.6); HATG, y = 15.285 + 20.162x, r = 0.829 (if x = 2.0, y = 55.6, 95% CI of y 44.4 to 66.8); HTG, y = 14.945 + 24.134x, r = 0.839 (if x = 2.0, y = 63.2, 95% CI of y 48.4 to 78.1). Peritoneal solute transport type has a major effect on peritoneal creatinine clearance, but an insignificant effect on peritoneal urea clearance. Consequently, the majority of anuric patients who achieve a weekly Kt/V urea of 2.0 will have a weekly NC cr lower than 60 liter/1.73 m2 and will require a Kt/V urea much higher than 2.0 to achieve the target NCcr of 60 liter/1.73 m2 weekly. The current targets of urea and creatinine clearance are not compatible in anuric patients on CAPD.

Adult↗
PubMed1998

Compliance in CAPD and CCPD patients as measured by supply inventories during home visits.

This study was performed to determine compliance with prescribed exchanges in continuous ambulatory peritoneal dialysis (CAPD) and continuous cycler peritoneal dialysis (CCPD) patients via a home supply inventory, to evaluate numerous other factors against this standard, and to compare compliant and noncompliant patient characteristics and outcomes. It was an open enrollment of patients with prospective follow-up of 49 CAPD and CCPD adult patients at a university dialysis center. Two home visits for dialysis solution inventories were conducted 1 to 3 months apart. The number of exchanges actually performed (based on the inventory and deliveries) divided by the number of exchanges prescribed determined the percent compliance. Patient self-evaluation of compliance, attitudes about compliance and medical care, Derogatis Affects Balance Sheet (DABS) (a validated tool of affects balance), staff evaluations, patient demographics, hospitalizations, dialysis adequacy (measured to predicted creatinine ratio) and patient outcomes were evaluated against compliance with prescribed exchanges. Thirty-five percent of the patients were found to be noncompliant with prescribed exchanges based on the supply inventory, performing only 74% of exchanges. Compliant and noncompliant patients were not different by age, race, gender, peritoneal dialysis (PD) time, number of comorbid conditions, nor incidence of diabetes. The affects balance score from the DABS test was a poor predictor of compliance, as were staff evaluations. Delivered dialysis, adjusted for percentage of compliance, was significantly lower in noncompliant than in compliant patients by weekly Kt/V (2.2 v 1.74, P < 0.003), Ccreatinine L/week/1.73m2 (69 v 58, P = 0.05), as was normalized protein nitrogen appearance rates (nPNA), g/kg/day (0.89 v 0.70, P = 0.001). Technique survival was significantly lower (P < 0.05) in noncompliant patients. Twenty-nine percent of the noncompliant patients transferred to hemodialysis for uremia compared with 6% of compliant patients, P = .04, with a mean follow-up time of 1 year per patient. Patient survival did not differ in the two groups. Peritonitis rates were higher in noncompliant than compliant patients (1.03/yr v 0.66/yr, P < 0.03), as were days hospitalized (908 per 100 patient-years v 1,016 per 100 patient-years, P < 0.04). Noncompliance with PD exchanges is significantly common in CAPD and CCPD patients. It occurs in one third of the patients at our center and contributes significantly to technique failure, inadequate dialysis, and an increased risk of both peritonitis and hospitalized days. Home visits to conduct supply inventories provide an excellent method of monitoring compliance.

Attitude to Health↗
PubMed1998

The risk of hernia with large exchange volumes.

Large exchange volumes of 2.5 and 3 L are frequently necessary to improve clearances to the level suggested by the DOQI guidelines. However, abdominal wall hernias are a well known complication of peritoneal dialysis (PD) related to increased abdominal pressure, and might increase with higher exchange volumes. We studied the effect of using higher exchange volumes in PD patients on the incidence of hernia formation. Seventy-nine (12%) of 656 PD patients over a 15-year span developed abdominal wall hernias. Eleven percent of patients using 2 L or smaller volumes, 15% of patients using more than 2 L but less than 3 L, and 13% of patients using 3 L developed hernias (not significantly different). Five percent of patients on cyclers for their entire PD experience (3 of 63 patients) developed one or more hernias, compared to 13% of patients on continuous ambulatory peritoneal dialysis for at least part of their experience (P = 0.06). The use of larger volumes increased dramatically over time; only 11% of patients used more than 2-L exchange volumes during the years 1982 through 1986, compared to 73% in the period from 1992 to 1997. We conclude that increased volumes in PD patients do not lead to an increased risk of hernia formation. Exchange volumes can be increased as needed to improve clearances.

Dialysis Solutions↗
PubMed1997

Estimating the daily dialysate drain volume required in CAPD for a target peritoneal creatinine clearance by body water and peritoneal transport characteristics.

Stepwise logistic regression performed in 324 clearance studies in 194 patients identified daily drain volume normalized by body water (DV/V) and peritoneal solute transport type as the predictors of peritoneal creatinine clearance (CCrp) in continuous ambulatory peritoneal dialysis (CAPD). Solution of the regression model for DV/V provided DV/V values predicted to provide a desired CCrp at different probabilities. The ability of the predicted DV/V to detect desired CCrp values was tested in a new set of 359 clearance studies in 217 CAPD patients who had a peritoneal equilibration test within 12 months of the clearance study. No patient with low transport had a CCrp exceeding 54 L/1.73 m2 weekly. The following DV/V values detected CCr > or = 54 L/1.73 m2 weekly with a probability of at least 80%: for low-average transport, 0.406 L/L per 24 hours; for high-average transport, 0.339 L/L per 24 hours; for high transport, 0.241 L/L per 24 hours. Corresponding DV/V values for a CCrp of 60 L/1.73 m2 weekly were as follows: for high-average transport, 0.351 L/L per 24 hours; for high transport, 0.271 L/L per 24 hours. For high-average transport, maximal body surface area (BSA) estimates allowing a CCrp of 60 L/1.73 m2 weekly at a CAPD schedule of four daily exchanges with 3-L exchange volume and 1.5 L/24 hour ultrafiltration volume, and with the specified DV/V values were 2.03 m2 in women and 1.77 m2 in men. Corresponding BSA estimates for high peritoneal solute transport were 2.58 m2 in women and 2.21 m2 in men. The delivered dose of CAPD, expressed as DV/V, required to achieve a target CCrp can be calculated from multivariate statistical models taking into account the peritoneal solute transport type. Multiplication of the required DV/V by V provides an estimate of the required daily exchange volume. Maximal BSA estimates allowing a target CCrp can be calculated for each gender and peritoneal solute transport type.

Biological Transport↗