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UNLABELLED: For renal replacement therapy, overall survival is more important than the choice of currently available individual therapy. Objectives. To compare patients and technique survival on peritoneal dialysis as first treatment (PDF) versus after previous haemodialysis (HDPD) and other indicators of follow-up. Methods. We prospectively studied 110 incident patients, during the period from August 4, 1993, to June 30, 2012, for patients and technique survival (Kaplan-Meier) (log rank P < 0.05). Results. Groups: (A) PDF: 37 patients, 24 females, age: 52.2 ± 14.9 years old, time at risk: 2123 patient-months (p/m), mean: 57 ± 42 months; (B) HDPD: 73 patients, 42 females, age: 52.45 ± 14.7 years old, time in haemodialysis: 3569.2 (p/m), range: 3-216 months, mean: 49 ± 45 months, time at risk in PD: 3700 (p/m), mean: 51 ± 49 months. Patients' survival: (A) PDF: 100%, 76.6%, 65.6%, and 19.7%; (B) HDPD: 95.4%, 65.6%, 43%, and 43% at 12, 60, 120, and 144 months, respectively, P = 0.34. TECHNIQUE: (A) PDF: 100%, 90%, 59.8%, and 24%; (B) HDPD: 94%, 75%, 32%, and 32% at 12, 60, 120, and 144 months, respectively, P = 0.40. Conclusions. Comparable patient and technique survival were observed. Peritoneal dialysis enables a greater extension of renal replacement therapy for patients with serious difficulties continuing with haemodialysis.

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Peritonitis (P) is the most important infectious complication in peritoneal dialysis (PD), but disagreement remains about the impact of PD modality on the frequency of P episodes. We compared indices linked to P between patients on continuous ambulatory PD (CAPD) and those on automated PD (APD) in the short and very long term. The study included 9 prevalent and 72 incident patients on CAPD (twin-bag system) and 37 incident patients on APD from 4 August 1995 to 31 March 2011. Data were collected prospectively from our database. The cumulative P rate (CPR) by weighted Student t-test (p < 0.05) expressed as the probabilities of remaining free of a first P episode and remaining free of all P episodes were compared by the Kaplan-Meier method (log rank p < 0.05). The proportion of patients with P (PPP) per group (chi2 p < 0.05) and the relative risk (RR) of P were also calculated. The CAPD patients included 51 women and 30 men [mean age.: 50.2 +/- 14.21 years (range: 15-82 years); duration of treatment: 3579 patient-months (mean: 44.2 +/- 34.2 patient-months); P episodes: 111] had a CPR of 0.38 episodes (1 episode in 31.35 patient-months) and a P rate per year (PRY) in the range 0.08-0.89 episodes. The APD patients [23 women and 14 men; mean age: 53.62 +/- 13.61 years (range: 26-78 years); duration of treatment: 1718 patient-months (mean: 46.4-38.3 patient-months); P episodes: 46] had a CPR of 0.32 episodes (1 episode in 373 patient--months) and a PRY in the range 0-1.12 episodes. At 1, 3, 5, and 10 years respectively, a first P episode occurred in 73%, 36%, 23%, and 8% of CAPD and 72%, 59%, 35%, and 23% ofAPD patients (log-rank p = 0. 056; CPR: p = 0.01; PPP: chi2 p = 0.39), for a RR of 0.83 linked to CAPD compared with APD. A lower P frequency and a trend of less time to first P was observed for APD compared with CAPD. The CAPD patients did not show a higher risk of developing P than did the APD patients. For comparisons between the modalities, CPR is a reliable index in the very long term at risk. Depending on the size of the population and the time at risk, the PRYobtained on short follow-up could result in a misinterpretation of the performance of each treatment modality.

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In a chronic disease, traineeship in the methodology to be used to treat oneself is a key part of success from the beginning and during long-term treatment. In chronic peritoneal dialysis (PD), peritonitis emphasizes, in a certain way, the result of the apprenticeship. We set out to evaluate the relationship between the number of PD training lessons and the frequency of peritonitis. According to the number of lessons, we established three groups: A, up to 8 lessons; B, 9-13 lessons; and C, 14 or more lessons. We evaluated peritonitis rates and micro-organisms, and for the three groups, we compared (Kaplan-Meier method) peritonitis-free survival (PFS) at 1 year of treatment, with significance set at (log rank) p < 0.05. The study enrolled 90 patients (mean age: 51.5 +/- 15.33 years; 37 men). Respectively, groups A, B, and C included 27, 46, and 17 patients with an at-risk duration of 1535, 2879, and 665 patient-months (mean: 56.9 +/- 44, 62.6 +/- 47, and 39.1 +/- 37.8 patient--months), of whom 35%, 37%, and 24% experienced no peritonitis, for peritonitis rates of 0.31, 0.37, and 0.47, with coagulase-negative Staphylococcus (CNS) peritonitis rates of 0.125, 0.12, and 0.235, and PFS rates of 76.9%, 80.4%, and 70.6%. The PFS was not significantly different between the groups (p > 0.05). During 1 year of treatment, all three groups experienced a satisfactory PFS. More frequent retraining should be considered in patients who needed more training lessons at the start of PD.

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La peritonitis (P) ha sido la complicación más importante de la diálisis peritoneal crónica (DPC) y la causa más frecuente de exclusión del programa. En este trabajo se evaluaron los índices de seguimiento de las P en DPC en 2 períodos consecutivos de 10 años en un hospital universitario, tras los avances de la técnica dialítica y la aplicación de un programa de educación médica continua y de los pacientes.(AU)

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La peritonitis (P) ha sido la complicación más importante de la diálisis peritoneal crónica (DPC) y la causa más frecuente de exclusión del programa. En este trabajo se evaluaron los índices de seguimiento de las P en DPC en 2 períodos consecutivos de 10 años en un hospital universitario, tras los avances de la técnica dialítica y la aplicación de un programa de educación médica continua y de los pacientes.

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Large body surface area (BSA) could be a pitfall in long-term peritoneal dialysis. We analyzed the viability of the peritoneum in terms of adequacy and technique survival in patients of varying BSA. We grouped our PD patients into three categories (BSA < or = 1.59 m2, BSA 1.60 - 1.79 m2, and BSA > or = 1.80 m2) and used the Student t-test to compare the mean weekly Kt/V urea between the groups (significance set at p < 0.05). We also measured and used Kaplan-Meier analysis to compare technique survival overall and in anuric patients from the onset of PD to the endpoints of transfer to hemodialysis or death linked to dialysis technique (log-rank test, p < 0.05). Group A consisted of 24 patients [2 men, 22 women; age: 41.9 +/- 12 years; BSA: 1.49 +/- 0.07 m2; total treatment duration: 1703.4 patient-months (mean: 71 +/- 50.6 months); diabetic: 8.33%; anuric: 62%; weekly Kt/V urea: 2.36 +/- 0.45; technique survival: 100%, 89%, 89%, 53%, and 53% at 1, 3, 5, 8, and 15 years]. Group B consisted of 35 patients [12 men, 23 women; age: 57.19 +/- 18 years; BSA: 1.69 +/- 0.05 m2; total treatment duration: 1870 patient-months (mean: 53.4 +/- 462 months); diabetic: 17.14%; anuric: 37.14%; weekly Kt/V urea: 2.28 +/- 0.41; technique survival: 97%, 93%, 87%, 78%, and 19% at 1, 3, 5, 8, and 14 years]. Group C consisted of 34 patients [24 men, 10 women; age: 56.2 +/- 13 years; BSA: 1.90 +/- 0.09 m2; total treatment duration: 1557.5 patient-months (mean: 45.8 +/- 34.4 months); diabetic: 20.6%; anuric: 41%; weekly Kt/V urea: 1.98 +/- 0.38; technique survival: 97%, 79%, 67.6%, 56%, and 28% at 1, 3, 5, 8, and 12 years]. Using the log-rank test, comparisons of technique survival overall and in anuric patients showed for A vs. B, p = 0.49 and p = 0.58 respectively; for A vs. C, p = 0.45 and p = 0.06; for B vs. C, p = 0.56 and p = 0.10. No significant differences in weekly Kt/V urea were observed between the groups (all p > 0.05). Peritoneal dialysis is viable for patients with a high BSA. There is a tendency toward worse technique survival in anuric patients with a high BSA.

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The durability of the peritoneum as a dialysis membrane is as yet an unanswered question. Peritonitis episodes have an important effect in long-term treatment. To evaluate survival of the peritoneum for dialysis, we analyzed peritoneal failure related to technique dropout because of peritonitis, inadequate dialysis, and ultrafiltration disorders. We retrospectively analyzed data for 89 peritoneal dialysis patients who had been treated for at least 3 months [52 women, 37 men; mean age: 50.91 +/- 13.72 years (range: 22 - 81 years)] from August 4, 1993, to July 1, 2008. The Kaplan-Meier method was used to measure peritoneum survival, with only a definitive switch to hemodialysis or death from peritonitis, ultrafiltration failure, or inadequate dialysis as endpoints. Total treatment time was 5008 patient-months (mean: 55 +/- 44 patient-months), and the historical annual rate of peritonitis was 0.37 per year at risk (1 episode in 32.52 patient-months). Of the 89 patients, 19 dropped treatment because of peritonitis and 1 because of ultrafiltration failure. Peritoneum survival was 98.8%, 93.7%, 87.6%, 66.9%, 46.4%, and 33.8% at 1, 3, 5, 8, 10, and 14 years. In the 15 years of our program, peritoneum failure represented less than 1.5% of drop-out causes annually. The peritoneum is a reliable membrane to reach dialysis targets in long-term therapy.

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Several studies have suggested an increased prevalence of osteopenia in dialysis. Peripheral quantitative computed tomography (pQCT) is a new technique that allows the noninvasive evaluation of trabecular and cortical bone separately. The aim of the study was: (1) to evaluate cortical bone by pQCT in continuous ambulatory peritoneal dialysis (CAPD) patients and compare the data with that obtained in healthy controls; and (2) to correlate cortical bone parameters with bone mineral density (BMD) of the lumbar spine and femoral neck and total bone mineral content (TBMC). Cortical bone parameters were obtained in 22 CAPD patients and 27 healthy individuals at the distal radius using a Stratec XCT 960 pQCT machine. In the dialysis patients, we also determined BMD and TBMC by bone densitometry. Dialysis patients, compared with controls, showed a significant reduction in volumetric cortical BMD (VcBMD) (p = 0.04) and cortical thickness (cThk) (p < 0.0001) with a significant increase in radial total cross-sectional area (TA) (p = 0.006), endosteal circumference (p < 0.0001), and buckling ratio (p < 0.0001). In CAPD patients, total time on dialysis correlated negatively with radial total BMD (p < 0.01) and VcBMD (p < 0.01). Age correlated positively with TA (p < 0.01), endosteal (p < 0.01), and periosteal circumferences (p < 0.01). Serum intact parathyroid hormone (PTH) levels correlated positively with endosteal (p = 0.04) and periosteal perimeter (p = 0.01). Total alkaline phosphatase correlated negatively with VcBMD (p < 0.01), and positively with endosteal perimeter (p = 0.02). Total bone mineral content correlated significantly with radial cortical content (p < 0.001), cross-sectional cortical area (cA; p < 0.001), and cThk (p < 0.01) but not with total radial BMD, VcBMD, or buckling ratio. No correlations were found between radial cortical parameters and BMD measured at the lumbar spine or femoral neck. We conclude that dialysis patients show cortical osteopenia with marked cortical thinning partially mediated by PTH action on bone. Total bone mineral content correlated with various radial cortical parameters (content, area, and thickness) but not with others. No correlations were found between cortical bone parameters measured at the peripheral skeleton with areal bone density measured at the axial skeleton. These findings suggest that pQCT may be a new tool in the assessment of bone fragility in dialysis patients.

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BACKGROUND: The usefulness of bone mass measurements and bone turnover markers to estimate the risk of fracture and the type of underlying renal osteodystrophy are not well established in patients on peritoneal dialysis (PD). OBJECTIVE: To assess bone mass using total and regional bone densitometry in a group of patients on PD and to determine if serum markers of bone turnover identify patients with low bone mass. METHODS: Bone densitometry was studied by dual-energy x-ray absorptiometry (DEXA), and bone turnover using several serum markers, in 65 patients on PD. Bone mass was classified as normal, osteopenic, or osteoporotic according to World Health Organization criteria based on bone mineral density (BMD) T scores. RESULTS: T scores in the osteopenia range were present at the lumbar spine (LS) in 44.6% (45% of men and 44.4% of women) of patients and at the femoral neck (FN) in 56.9% (55% of men and 58% of women). T scores in the osteoporosis range were present at the LS in 13.8% of patients (10% of men and 15.5% of women) and at the FN in 21.5% (30% of men and 17.7% of women). Patients with BMD T scores in the osteoporosis range at both regions had increased serum intact parathyroid hormone (iPTH) levels compared to patients in the osteopenic/normal range. Bone mineral content in the whole skeleton (TBMC) correlated negatively with iPTH (r = -0.34) and with total time on dialysis (r = -0.26); in multivariate analysis, only iPTH correlated negatively with TBMC (B = -0.26, p = 0.03). No correlations were found between the other bone markers and BMD T scores at the FN or LS. There were no significant differences in absolute BMD or BMD T scores at the LS or FN between patients with and patients without fractures. CONCLUSIONS: BMD T scores in the osteopenia/osteoporosis range were observed at the LS in 58.4% of these patients on PD and at the FN in 78.4%. TBMC correlated negatively with iPTH. There were no correlations between markers of bone turnover and bone mass measurements at the two skeletal regions, although patients with BMD T scores in the osteoporosis range had increased serum iPTH levels. Bone mass measurements were not different between patients with and patients without fractures.

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BACKGROUND: Malnutrition is widely prevalent in dialysis. Malnourished patients present depletion of somatic protein stores and a decrease in lean body mass (LBM) that can be measured by different techniques. AIMS: (1) To assess the reliability of lean mass measurements obtained by creatinine kinetics (CrK) in a group of stable peritoneal dialysis (PD) patients, using dual-energy x-ray absorptiometry (DEXA) measurements as the reference method; (2) to establish the reproducibility of LBM estimated by CrK in individual patients analyzing repeated measurement in the short term, and (3) to correlate measurements of LBM with laboratory determinations that assess nutritional status. METHODS: We performed a cross-sectional evaluation of LBM by DEXA and CrK in 39 PD patients. In 14 patients we performed repeated measurements of LBM by CrK in the short term. RESULTS: No significant difference was found in mean lean mass values estimated by both methods: mean DEXA LBM was 41.7 kg, 36.1 +/- 4.5 kg in females and 52.7 +/- 6.4 kg in males and mean CrK LBM was 41.08 kg, 37.5 +/- 6.1 kg in females and 48.1 +/- 8.4 kg in males. A good correlation was found between both techniques (r = 0.71; p < 0.003). The mean difference between the two methods was 0.638 +/- 6.95 kg (95% confidence limits: -12.98 and +14.26). A wide scatter of the differences between both methods was seen throughout the range of measurements of LBM. When LBM by CrK was repeatedly (2-3 times) measured in a period of 3-4 months in 14 patients, it had a coefficient of variation (CV) of 15.39% (range 2.89-42.88%), while body weight CV in the same period was 0.69% (range 0-1.9%). CONCLUSIONS: CrK is an unsatisfactory method for the assessment of LBM in PD patients.

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La naturaleza progresiva de la insuficiencia renal crónica (IRC), que inexorablemente lleva a la supresión de la función renal y la búsqueda de algún medio capaz de enlentecer su avance, han sido motivos que dieron origen a este trabajo. El estudio retrospectivo de un número importante d epacientes con IRC de distinta etiología, nos permitió conocer las características evolutivas para cada grupo. El estudio prospectivo, donde se utilizó una metodología para prescribir la dieta hipoproteica (DHP) desarrollada en el Instituto de Investigaciones Médicas años atrás, cuando la preocupación pasaba por la necesidad de aliviar los sintomas urémicos sin generar balance nitrogenado negativo, nos permitió efectuar DHP adecuadas a cada paciente en particular y luego, efectuar una evolución pormenorizada de la respuesta funcional renal al tratamiento y, también, estudiar el efecto del mismo sobre la velocidad de progresión de la enfermedad. La respuesta funcional a la DHP observada, apoya la hipótesis que postula la presencia de hiperfiltración en los pacientes con IRC alimentados ad libitum. El análisis del ritmo de progresión previo y posterior al tratamiento dietético, muestra que, la supresión de la hiperfiltración mejora la evolución de la IRC entre los 6 y 12 meses posteriores al comienzo de la dieta (AU)

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La naturaleza progresiva de la insuficiencia renal crónica (IRC), que inexorablemente lleva a la supresión de la función renal y la búsqueda de algún medio capaz de enlentecer su avance, han sido motivos que dieron origen a este trabajo. El estudio retrospectivo de un número importante d epacientes con IRC de distinta etiología, nos permitió conocer las características evolutivas para cada grupo. El estudio prospectivo, donde se utilizó una metodología para prescribir la dieta hipoproteica (DHP) desarrollada en el Instituto de Investigaciones Médicas años atrás, cuando la preocupación pasaba por la necesidad de aliviar los sintomas urémicos sin generar balance nitrogenado negativo, nos permitió efectuar DHP adecuadas a cada paciente en particular y luego, efectuar una evolución pormenorizada de la respuesta funcional renal al tratamiento y, también, estudiar el efecto del mismo sobre la velocidad de progresión de la enfermedad. La respuesta funcional a la DHP observada, apoya la hipótesis que postula la presencia de hiperfiltración en los pacientes con IRC alimentados ad libitum. El análisis del ritmo de progresión previo y posterior al tratamiento dietético, muestra que, la supresión de la hiperfiltración mejora la evolución de la IRC entre los 6 y 12 meses posteriores al comienzo de la dieta (AU)

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La naturaleza progresiva de la insuficiencia renal crónica (IRC), que inexorablemente lleva a la supresión de la función renal y la búsqueda de algún medio capaz de enlentecer su avance, han sido motivos que dieron origen a este trabajo. El estudio retrospectivo de un número importante d epacientes con IRC de distinta etiología, nos permitió conocer las características evolutivas para cada grupo. El estudio prospectivo, donde se utilizó una metodología para prescribir la dieta hipoproteica (DHP) desarrollada en el Instituto de Investigaciones Médicas años atrás, cuando la preocupación pasaba por la necesidad de aliviar los sintomas urémicos sin generar balance nitrogenado negativo, nos permitió efectuar DHP adecuadas a cada paciente en particular y luego, efectuar una evolución pormenorizada de la respuesta funcional renal al tratamiento y, también, estudiar el efecto del mismo sobre la velocidad de progresión de la enfermedad. La respuesta funcional a la DHP observada, apoya la hipótesis que postula la presencia de hiperfiltración en los pacientes con IRC alimentados ad libitum. El análisis del ritmo de progresión previo y posterior al tratamiento dietético, muestra que, la supresión de la hiperfiltración mejora la evolución de la IRC entre los 6 y 12 meses posteriores al comienzo de la dieta

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