Magnesium in Dialysate: Is Less More? Samad, Nasreen; Monte, Cheryl E.
Journal of the American Society of Nephrology,
11/2023, Letnik:
34, Številka:
11S
Journal Article
Malnutrition and protein energy wasting (PEW) determined by Subjective Global Assessment (SGA) is associated with increased mortality. There is an inverse relationship between body mass and ...overhydration in dialysis patients. Is the predictive accuracy of SGA (for death) independent of hydration status? Can bioimpedance spectroscopy analysis of lean tissue index (LTI) and fat tissue index (FTI) accurately identify dialysis patients with protein energy wasting and increased mortality?
We report an observational study of 455 peritoneal dialysis (PD) patients.
We found that 96 patients (21%) were malnourished (SGA score between 1 and 5), and 192 (42%) had LTI values below 10th centile (age, gender adjusted). FTI was significantly lower in the SGA-defined malnourished cohort. By contrast, there was an inverse relationship between LTI and FTI. Malnourished (by SGA) patients were significantly more overhydrated (P < .0001), but SGA remained highly predictive of survival in multivariate analysis that included hydration status (hazard ratio: 3.12, 95% confidence interval 1.86-5.23, P < .0001). Obesity (patients with the highest 20% FTI) predicted survival (hazard ratio of death was 0.47, 95% confidence interval 0.16-0.85, P < .02) on univariate but not multivariate analysis.
We have confirmed that SGA is an accurate predictor of mortality in PD patients, and its predictive value is independent of the hydration status. Predictive power of SGA was not affected when LTI and FTI were included in multivariate analysis. Patients with low LTI were different from patients with low SGA (associated with high FTI). Sensitivity and specificity of Body Composition Monitor to diagnose patients with low SGA readings were poor (area under the curve for receiver operator characteristics analysis 0.66). The phenomenon of reverse epidemiology (high FTI predicting a survival advantage) was found in our PD cohort.
Background
Patients on automated peritoneal dialysis (APD) may have greater exposure to glucose in the PD fluid than those on continuous ambulatory PD (CAPD). If this causes long-term damage to the ...peritoneal membrane, it will have implications for a patient's choice of modality.
Methods
Membrane function of long-term APD or CAPD patients was followed prospectively. The data were collected from electronic patient records in our unit from 2000 to 2014. The rate of change in membrane transport status (D/Pcr) and ultrafiltration (UF4) for each patient was calculated using the least square regression line equation.
Results
We identified 106 APD and 123 CAPD patients who had a mean of 8.4 peritoneal equilibration test (PET) over 5.6 years. No differences were found in the rate of changes in D/Pcr or UF4. Baseline solute clearance (Kt/V) was lower in APD patients (1.66 vs 1.76, p = 0.04). However, APD patients experienced incremental changes to dialysis prescription that resulted in a greater increase in Kt/V compared with CAPD patients.
Conclusion
This is the largest study comparing the long-term effect of APD vs CAPD prescriptions. Despite more glucose being prescribed, there were no differences in the evolution of peritoneal membrane transport characteristics. The lower baseline Kt/V of APD patients might be explained by our aggressive use of incremental APD (tidal with dry day). Despite greater glucose prescriptions, initiating patients on APD based on patient preference appears to be safe for the long-term integrity of the peritoneal membrane.
Objective: This study aims to provide information on the perceptions of and practices used for diabetes in the UAE with the view to generate evidence-based strategic guidelines for future programs.
...Method: A multi-method approach was used. It included a survey to collect data on the current level of awareness, attitudes, and behaviors among diabetic and non-diabetic samples in Al Ain, UAE. We reviewed the literature on the social marketing framework and its suitability to diabetes control and prevention programs.
Results: Knowledge about the disease was generally low. The level of awareness among members of the diabetic group, however, was found to be slightly better than that of their non-diabetic counterparts. Practices related to diabetic care were mixed. Social marketing is a recognized intervention method for influencing behavior and has been used effectively in various health programs worldwide.
Conclusions: Low awareness of diabetes would further increase the number of diabetes and diabetes-related complications in future years, putting an enormous burden on the healthcare system. A social marketing intervention focusing on behavioral change can offer an effective solution.
Aim
Peritoneal dialysis peritonitis and fluid overhydration (OH) are frequent problems in peritoneal dialysis. The latter can cause gut wall oedema or be associated with malnutrition. Both may lead ...to increased peritonitis risk. We wished to determine if OH is an independent risk factor for peritonitis (caused by enteric organisms).
Methods
Retrospectively study of patients with >2 bioimpedance assessments (Body Composition Monitor). We compared peritonitis rates of patients with above or below the median time‐averaged hydration parameter (OH/extracellular water, OH/ECW). Multivariate analysis was performed to determine independent risk factors for peritonitis by enteric organism.
Results
We studied 580 patients. Peritonitis was experienced by 28% patients (followed up for an average of 17 months). The overall peritonitis rate was 1:34 patient months. Patients with low OH/ECW values had significantly lower rates of peritonitis from enteric organisms than overhydrated patients (incident rate ratio 1.53, 95% confidence interval 1.38–1.70, P < 0.001). Hydration remained an independent predictor of peritonitis from enteric organisms when multivariate model included demographic parameters (odds ratio for a 1% increment of OH/ECW was 1.05; 95% confidence interval 1.01–1.10, P < 0.02). However, including biochemical parameters of malnutrition reduced the predictive power of overhydration.
Conclusion
We found an association between overhydration and increased rates of peritonitis. While this may partly be due to the high co‐morbidity of patients (advanced age and diabetes), on multivariate analysis, only inclusion of nutritional parameters reduced this association. It remains to be determined if overhydration will prove to be a modifiable risk factor for peritonitis or whether malnutrition will prove to be more important.
Summary at a Glance
Fluid overload is a very important risk factor on all cause mortality and residual function. This paper tried to investigate how to measure a fluid status and avoid potential modifiable risk factor for peritonitis in patients on peritoneal dialysis. It is great benefit for peritoneal dialysis doctors in their clinical practice.
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