La dialisi peritoneale offre diversi vantaggi rispetto all'emodialisi, inclusa una migliore qualità di vita. Nonostante la sua evoluzione scientifica e tecnologica, resta una metodica marginale. A ...nostro avviso, aIcuni dei principali fattori responsabili della bassa penetranza della dialisi peritoneale sono da ricercare nella debole motivazione dei nefrologi, appesantita da un aggiornamento spesso inadeguato di medici e infermieri, dalla scarsa formazione dei medici specializzandi e dalla mancanza di un ambulatorio correttamente organizzato con personale motivato e dedicato. Ulteriori investimenti ad ampio spettro sono, quindi, necessari per risollevare le sorti della dialisi peritoneale; tra essi, l'investimento sulla ricerca, sulla formazione e sull'integrazione tra ospedale e territorio.
Peritoneal dialysis (PD) is an effective renal replacement therapy for the treatment of end-stage renal disease. Patients on PD undergoing abdominal open surgery often fail to resume PD. Laparoscopic ...surgery has recently become a serious alternative to open surgery in patients on PD to treat different abdominal pathologies. However, only a few studies have reported successful procedures without Tenckhoff catheter removal. The aim of this review is to describe how a laparoscopic technique can allow PD patients to deal with abdominal surgery without shifting to hemodialysis. Only 50 cases of laparoscopic surgical intervention in PD patients have been published to our knowledge. These case series largely concern laparoscopic cholecystectomies, appendectomies, nephrectomies, colectomies, and bariatric procedures. The reported cases show how laparoscopic surgery can be accepted as a valid option for several abdominal surgical procedures in patients on PD with good outcomes and early resumption of PD.
In chronic nephropathies, inhibition of angiotensin-converting enzyme (ACE) is renoprotective, but can further renoprotection be achieved by reduction of blood pressure to lower than usual targets? ...We aimed to assess the effect of intensified versus conventional blood-pressure control on progression to end-stage renal disease.
We undertook a multicentre, randomised controlled trial of patients with non-diabetic proteinuric nephropathies receiving background treatment with the ACE inhibitor ramipril (2·5–5 mg/day). We randomly assigned participants either conventional (diastolic <90 mm Hg; n=169) or intensified (systolic/diastolic <130/80 mm Hg; n=169) blood-pressure control. To achieve the intensified blood-pressure level, patients received add-on therapy with the dihydropyridine calcium-channel blocker felodipine (5–10 mg/day). The primary outcome measure was time to end-stage renal disease over 36 months' follow-up, and analysis was by intention to treat.
Of 338 patients who were randomised, three (two assigned intensified and one allocated conventional blood-pressure control) never took study drugs and they were excluded. Over a median follow-up of 19 months (IQR 12–35), 38/167 (23%) patients assigned to intensified blood-pressure control and 34/168 (20%) allocated conventional control progressed to end-stage renal disease (hazard ratio 1·00 95% CI 0·61–1·64; p=0·99).
In patients with non-diabetic proteinuric nephropathies receiving background ACE-inhibitor therapy, no additional benefit from further blood-pressure reduction by felodipine could be shown.
ABSTRACT
Backgound
Fungal peritonitis (FP) is one of the most important causes of peritoneal dialysis (PD) failure, often burdened by increased morbility and mortality. This study evaluates the ...clinical course of FP cases that arose between 1983 and 2016 in a single PD unit.
Methods
We conducted a retrospective observational analysis of FP episodes recorded in the Baxter POET (Peritonitis Organism Exit sites Tunnel infections) registry and clinical records. FP incidence rate, PD and patients' survival and clinical characteristics of the study population were analysed, taking into account the evolution of clinical practice during the study period as a result of technical innovation, scientific evidence and guideline history.
Results
Fourteen FP cases (2.8%) were detected. The overall incidence of PD peritonitis was one episode/27 patient-months. Candida parapsilosis was the most frequently (50%) detected yeast. Seventy-five per cent of cases were considered secondary FP. This group experienced 2.6±1.7 bacterial peritonitis before FP, most frequently due to Staphylococcus and Enterococcus species. Most patients were treated with fluconazole for ≥8 days. All subjects were hospitalized for a median time of 25 days. Tenckhoff catheter removal occurred in all cases of FP and all patients were transferred to haemodialysis. Two patients died. From December 2010 to December 2016, no FP episodes were recorded.
Conclusions
FP is confirmed as a significant cause of PD drop out and increases patients' mortality risk. Prompt diagnosis of FP, targeted antifugal therapy and rapid PD catheter removal are essential strategies for improved patient and PD survival.
A laparoscopic approach represents an effective alternative to open surgery in patients undergoing peritoneal dialysis (PD). In these patients, conventional thinking provides for removal of the ...peritoneal catheter during left colon resections because of higher risk of patient contamination and peritonitis. The present paper describes 3 cases of laparoscopic left hemicolectomy for colon cancer performed in PD patients without complications and without peritoneal catheter removal, leading to subsequent early PD resumption.
Three normotype PD patients affected by early-stage sigmoid colon adenocarcinoma (T1-T2, M0, N0) underwent integrated surgical and nephrological management to reduce peritoneum stress, infective risk and postoperative complications. The day before surgery, patients were shifted to isovolumetric hemodialysis through tunneled central venous catheter. All patients underwent laparoscopic left hemicolectomy without Tenckhoff catheter removal. The postoperative period was uneventful, with concomitant antibiotic prophylaxis until the fifth day after surgery. Flushing of the PD catheter was performed twice a week postoperatively. Peritoneal dialysis was recovered 4 weeks after surgery in 2 cases with a well-maintained dialytic adequacy. One patient did not proceed to PD due to improvement of renal function after surgery.
In selected PD patients, a minimally invasive surgical approach combined with careful nephrological management may represent a valid and safe strategy to treat early-stage colon cancer, avoiding PD drop-out.
Atrial fibrillation is the most frequent arrhythmia in patients on dialysis. Whereas it is associated with a higher thromboembolic risk in the general population, this association has not been ...unequivocally confirmed in dialysis patients. Furthermore, the potential benefits of oral anticoagulant therapy in uremia have been recently reviewed, given the increased risk of bleeding in these patients. Cardiologic guidelines to guide the choice of oral anticoagulant therapy by stratifying the thromboembolic and hemorrhagic risks were developed in the general population and their generalization to dialysis patients has not been validated. This paper will discuss the association between atrial fibrillation and thromboembolic risk in dialysis, presenting some strategies to evaluate the risk-benefit balance of oral anticoagulant therapy in dialysis patients affected by atrial fibrillation.
Abstract Background Patients on dialysis may have abnormal serum levels of Ca, P and parathyroid hormone, with related bone diseases. This population has an increased risk of death, with ...cardiovascular calcification (CC) a contributing factor. Patients on peritoneal dialysis appear to be at increased risk of hyperlipidemia, a contributing factor to atherosclerotic plaque formation. Although several studies have described the presence and progression of CC in hemodialysis populations, there are fewer data in patients on peritoneal dialysis. Study design The Renal Osteodystrophy and Calcifications: Key factors in Peritoneal Dialysis (ROCK-PD) study was a 36-month, prospective observational study conducted in Italy. The study examined the presence and progression of CC in two cardiac valves and five arterial sites. The potential associations of serum Ca and P with mortality and cardiovascular morbidity, demographic, clinical and blood chemistry variables was investigated. Results CC was present in 77% of patients at baseline ( N = 369) and in 90% of patients by study end ( N = 145), progressing in 73% of patients. There were 42 deaths (11%). Analyses showed a marked correlation between baseline P levels and the presence of left ventricular hypertrophy. However, there were no consistent correlations between serum Ca or P with mortality or morbidity. Conclusions CC was common in peritoneal dialysis patients and progressed in a majority of patients.
Only few cases of acute renal failure (ARF) requiring dialysis have been reported in patients with idiopathic nephrotic syndrome (NS). This study aims to better define the clinical outcome and ...treatment of this condition.
A pilot enquiry regarding the occurrence of ARF requiring dialysis in patients with NS and biopsy proven minimal changes (MC) or focal segmental glomerulosclerosis (FSGS) was conducted among 5 nephrology centers.
From 1996-2006, 6 patients with idiopathic NS (4 MC, 2 FSGS) developed ARF requiring dialysis early after onset of NS. At presentation all but 1 patient had elevated blood pressure. Patients were treated with dialysis from 7-40 days. All achieved complete or partial remission after 4-8 weeks of steroids. Recovery of renal function paralleled with the reduction of proteinuria. At renal biopsy proximal tubules showed a large amount of protein droplets, flattening of epithelial cells, and focal detachment of cells from the basal membrane. After a follow-up of 24-60 months, 5 patients had a relapse. Of these 4 were responsive to steroids, while one progressed to dialysis after an episode of hemolytic uremic syndrome related to cyclosporine treatment. ARF did not recur.
ARF requiring dialysis is a rare and unexpected complication of idiopathic NS occurring in most cases early after presentation. These patients are sensitive to steroids that should be administered as promptly as possible in view of the potential noxious effect of protein overload on proximal tubular cells.
Background. In automated peritoneal dialysis (APD) one of the most important factors that influence the efficiency of the treatment is the total volume of dialysate infused per session and the dwell ...time. This study is aimed at examining the relationships between i.p. pressure (IPP), dialysate flow characteristics, and different dialysate fill volumes in order to optimize APD. Methods. We studied 20 patients who received APD, with the standard fill volume (2 l, A), or individualized fill volumes based on the patient’s body surface area (2.5 l/BSA/1.73 m, B) or on body weight (40 ml/kg body weight, C). The patient’s tolerance to a given fill volume was evaluated by measuring IPP, and catheter flow characteristics were evaluated by an automated machine. Results. IPP increased with the increase of the infused volume of dialysate (P < 0.05) and tended towards a positive relationship with the patient’s body mass index (BMI: A vs IPP: R = 0.39, P = 0.0019; B vs IPP: R = 0.66, P = 0.0012; C vs IPP R = 0.55, P = 0.009). We also found a relationship between fill volume, BMI and IPP: IPP = 1.0839 + 0.53 (β) × BMI + 0.211 (β) × fill volume (R = 0.65; r2 = 0.40 P < 0.01). The mean IPP with different dialysate fill volumes tended to be related to the volume of dialysate drained at the transition point (R = 0.37; P < 0.05). The pre-transition flow rate/mean IPP ratio tended towards a positive relationship with the volume of dialysate drained at the transition point (R = 0.35, P < 0.05), the transition time (R = 0.34; P < 0.05) and a negative one with the transition volume (R = –0.35, P = 0.05). Conclusion. It is possible to customize APD, where the tidal percentage coincides with the transition point for a given catheter and a specific initial dialysate fill volume, the tolerance of which can be measured by assessing IPP.
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