End-stage renal disease (ESRD) is associated with significantly increased morbidity and mortality resulting from cardiovascular disease (CVD) and infections, accounting for 50% and 20%, respectively, ...of the total mortality in ESRD patients. It is possible that these two complications are linked to alterations in the immune system in ESRD, as uremia is associated with a state of immune dysfunction characterized by immunodepression that contributes to the high prevalence of infections among these patients, as well as by immunoactivation resulting in inflammation that may contribute to CVD. This review describes disorders of the innate and adaptive immune systems in ESRD, underlining the specific role of ESRD-associated disturbances of Toll-like receptors. Finally, based on the emerging links between the alterations of immune system, CVD, and infections in ESRD patients, it emphasizes the potential role of the immune dysfunction in ESRD as an underlying cause for the high mortality in this patient population and the need for more studies in this area.
Objective
A bicarbonate/lactate peritoneal dialysis solution (Bic/Lac) has been developed based on in vitro and ex vivo data showing better preservation of cell function and correction of pain on ...infusion.
Design
This was a randomized, prospective, controlled, open-label study comparing a new 25 mmol/L bicarbonate/15 mmol/L lactate with a standard 40 mmol/L lactate-buffered peritoneal dialysis solution (Lac) over a 12-month treatment period.
Setting
17 European nephrology centers.
Patients
106 (70 Bic/Lac and 36 Lac) well-dialyzed continuous ambulatory peritoneal dialysis (CAPD) patients.
Interventions
Dialysis adequacy and peritoneal equilibration test (PET, week –4, months 3, 6, and 12); 24-hour ultrafiltration (week –4, months 1, 3, and 6); blood biochemistry (week –2, day 0, months 1, 2, 3,6, 9, and 12); and a product acceptability questionnaire (months 1 and 6).
Results
88 patients completed the first 6 months, and 44 the full year. The solutions were shown to be therapeutically equivalent with respect to plasma bicarbonate and peritoneal urea and creatinine clearances. Ultrafiltration in the Bic/Lac group increased significantly from baseline by about 150 mL/day for the whole of the 6-month treatment period ( p < 0.05). The biochemistry profile, adverse events, and physical examination (except body weight where there was a statistically significant increase in the Bic/Lac group) results did not differ significantly between the two groups. Reduced pain/discomfort on infusion or an increased sense of well-being was reported by 41% of patients on the Bic/Lac fluid.
Conclusions
The Bic/Lac solution is safe and effective in correcting uremic acidosis, provides relief of inflow pain/discomfort, and improves ultrafiltration and body weight.
Background Despite the theoretical benefits of biocompatible physiological-pH bicarbonate/lactate-buffered (B/L) peritoneal dialysis solution, there is only limited evidence supporting a superior ...clinical outcome associated with its use. Study Design Observational study. Settings & Participants 2,163 patients starting peritoneal dialysis therapy between July 2003 and December 2006 from 54 centers in Korea were enrolled. Predictors B/L solution and icodextrin use. Outcomes All-cause mortality and technique failure. Measurements Patient outcomes were compared between patients prescribed B/L and conventional solutions by using propensity score and intention-to-treat analyses. Results 542 patients initiated peritoneal dialysis therapy with B/L solution, and 1,621, with conventional solution. Fifteen patients prescribed B/L solution switched to conventional solution, and 386 of those initially using conventional solution switched to B/L solution during follow-up. Propensity score matching yielded 542 matched pairs of patients. In the matched cohort, there were no significant differences in age, diabetes, cardiovascular comorbidity, socioeconomic status, icodextrin use, or center experience between the 2 groups. All-cause deaths occurred in 52 (9.6%) patients in the B/L-solution group compared with 102 (18.9%) in the conventional-solution group (hazard ratio HR, 0.70; 95% confidence interval CI, 0.50 to 0.98; P = 0.04). In addition, icodextrin use was significantly associated with a reduced risk of death (HR, 0.40; 95% CI, 0.28 to 0.58; P < 0.001). Thirty-three (6.1%) and 48 (8.9%) technique failures occurred in the B/L- and conventional-solution groups, respectively (HR, 0.91; 95% CI, 0.58 to 1.43; P = 0.7). The survival benefit of B/L solution persisted in the unmatched cohort (HR, 0.69; 95% CI, 0.52 to 0.93; P = 0.02). Limitations Retrospective analysis, lack of laboratory data, and unknown indications for use of B/L solution. Conclusion Use of a biocompatible B/L peritoneal dialysis solution with physiological pH is associated with improved survival compared with conventional solution. Large randomized clinical trials are warranted to confirm this finding.
This comprehensive update on the management of encapsulating peritoneal sclerosis incorporates insights gained from recently published findings and the accumulated experience of the authors. Aspects ...covered include diagnosis, risk factors and predictive markers, treatment, and prevention, including criteria for withdrawal from peritoneal dialysis.
Immune dysfunction, resulting in infection or inflammation, or both, is closely associated with poor clinical outcome in end-stage renal disease patients. So far, no single measure can effectively ...address this condition, because many factors, such as uremia per se and dialysis treatment are involved in the pathogenesis. Our review focuses on currently available treatments and prevention options, and identifies future research needs.
Bicarbonate/lactate peritoneal dialysate increases cancer antigen 125 and decreases hyaluronic acid levels.
In a randomized, controlled trial comparing a pH neutral, bicarbonate/lactate ...(B/L)-buffered PD solution to conventional acidic, lactate-buffered solution (C), the overnight dialysate levels of markers of inflammation/wound healing hyaluronic acid (HA), mesothelial cell mass/membrane integrity cancer antigen 125 (CA125), and fibrosis transforming growth factor-β1 (TGF-β1) and procollagen I peptides (PICP) were assessed over a six-month treatment period.
One hundred six patients were randomized (2:1) to either the B/L group or C group. Overnight effluents were collected at entry into the study (time = 0 all patients on control solution) and then at three and six months after randomization. Aliquots were filtered, stored frozen, and assayed for HA, CA125, TGF-β1, and PICP. Differences between groups were assessed by repeated-measures analysis of variance for unbalanced data using the SAS procedure MIXED.
In patients treated with B/L, there was a significant (P = 0.03) increase in CA125 after six months compared with time = 0 (19.76 ± 11.8 vs. 24.4 ± 13.8 U/mL; mean ± SD; N = 51). In the same group of patients, HA levels were significantly decreased at both three and six months in the B/L-treated group (time = 0, 336.0 ± 195.2; time = 3 months, 250.6 ± 167.6; and time = 6 months, 290.5 ± 224.6 ng/mL; mean ± SD; P = 0.006, N = 47 and P = 0.003, N = 48, respectively). No significant changes in CA125 or HA levels were observed in the control group. There were no significant changes observed in the levels of PICP or TGF-β1 in the B/L or C group over the six-month treatment period.
These results suggest that continuous therapy with the B/L solutions modulates the levels of putative markers of peritoneal membrane integrity and inflammation. In the long term, this may positively impact the peritoneal membrane, increasing its life as a dialyzing organ.
Publications providing insights into the pathophysiology of, and therapeutic strategies for, EPS are the focus of the present review. Referenced publications are limited to those written in English.
ABSTRACT
Peritoneal dialysis technique survival in Australia and New Zealand is lower than in other parts of the world. More than two‐thirds of technique failures are related to infective ...complications (predominantly peritonitis) and ‘social reasons’. Practice patterns vary widely and more than one‐third of peritoneal dialysis units do not meet the International Society of Peritoneal Dialysis minimum accepted peritonitis rate. In many cases, poor peritonitis outcomes reflect significant deviations from international guidelines. In this paper we propose a series of practical recommendations to improve outcomes in peritoneal dialysis patients through appropriate patient selection, prophylaxis and treatment of infectious complications, investigation of social causes of technique failure and a greater focus on patient education and clinical governance.
This manuscript addresses the reasons why the peritoneal dialysis technique survival time is lower in Australia and New Zealand compared with many other parts of the world. The authors propose a series of practical recommendations to improve the outcomes in PD through appropriate patient selection, prevention and treatment of infectious complications, examining the causes of ‘social’ technique failure and addressing the need for a greater focus on patient education and clinical governance.
PDF
