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The prevalence of diabetes mellitus among patients treated for end-stage renal failure was studied using a questionnaire mailed to all dialysis units of mainland France in 1989. With a response rate of 80.8%, the study population amounted to 12,903 dialysed patients of whom 884 were declared diabetic (6.9%). In a second phase, the study focused on the diabetic patients treated in the 63 largest units (those with at least four diabetic patients). Seven specially trained physicians completed questionnaires after having interviewed the patients and checked their medical records. All this material was reviewed by the same diabetologist. The conflict of diabetes type declared by both sources of information (the nephrologists and the diabetologist) showed a misclassification rate of 31.2%. Using these new data, the prevalence of type 1 diabetes mellitus was estimated at 1.4% of patients on dialysis therapy in mainland France, and 5.5% for type 2 diabetes mellitus. A north-south declining trend was suggested for type 2 diabetes mellitus. Diabetic nephropathy was the only primary renal diagnosis among 93.9% of type 1 diabetic patients, but only for 36.8% of type 2 diabetic patients. Of the latter, 51.6% had a non-diabetic cause of renal failure. These data show that the proportion of diabetics among patients receiving dialysis, while steadily increasing in France, remains lower than in other countries in Europe and in North America. However, the validity of international comparisons depends on diabetes ascertainment. Heterogeneity in selection of patients and in diabetes type classification by dialysis units may account to a considerable degree for the differences between diabetes mellitus prevalence across countries.
Nephrol Dial Transplant 1992
PMID:Diabetes mellitus prevalence among dialysed patients in France (UREMIDIAB study). 133 35

A large end stage renal failure population treated by chronic ambulatory peritoneal dialysis (CAPD) was examined for rates of infection, CAPD modality failure and patient survival (N = 347). Nearly half were considered high risk for survival for reasons of age (39% older than 60 years), diabetes mellitus (33%), hemodialysis access failure (10%), poor cardiopulmonary reserve (16%) or technical challenges (30% had morbid obesity, history of abdominal aortic aneurysm repair or multiple abdominal surgeries). Hence, CAPD was often initiated by default rather than choice in the 347 patients studied (mean age: 51 +/- 17 years). Infections greatly outnumbered technical failures as grounds for cessation of CAPD. Over 5521 patient-months, 51% of patients developed infection with peritonitis predominating (80%) when compared to exit site infections (20%). The frequency of infections was 1.9 mean episodes per patient; however, 55% of these patients had only one episode of peritonitis. A rate of 0.75 infections per patient per year was seen with an average interval of 16 months between infections. Technique and patient survival rates at 4 years were 50% and 61% respectively. High risk status does not preclude successful CAPD and should not preclude its implementation.
Adv Perit Dial 1992
PMID:Single center success with a high risk peritoneal dialysis population. 136 61

Large numbers of diabetics with renal failure have been treated by continuous ambulatory peritoneal dialysis (CAPD). Overall 1-year patient survival varies from 51% to 87%. Mortality is due to cardiovascular disease in more than 50% of the cases. Young diabetics with good blood pressure control and without cardiac disease have a chance at long survival on CAPD. In comparison to hemodialysis, CAPD yields better patient survival for young diabetics and worse for old diabetics, worse technique survival, probably greater overall morbidity, and similar rates of progression of retinopathy, neuropathy and peripheral vascular disease. Adequacy of peritoneal clearance and peritoneal ultrafiltration characteristics are similar between diabetics and non-diabetics on CAPD. CAPD is associated with better preservation of renal function than hemodialysis in diabetics. The rates of CAPD peritonitis do not differ substantially between diabetics and non-diabetics. However, diabetes appears to be associated with higher incidence of tunnel infection. Hyperlipidemia is generally less severe in diabetics than non-diabetics on CAPD, but malnutrition is more frequent in diabetics. CAPD has many attractive features and several drawbacks for the management of diabetics with end stage renal failure (ESRF). Its ultimate success will depend on the outcome of efforts to improve cardiovascular mortality, malnutrition, hyperlipidemia and catheter-related infections.
Adv Perit Dial 1992
PMID:CAPD in end stage patients with renal disease due to diabetes mellitus--an update. 136 83

This study was undertaken to ascertain the effectiveness of an immobilization device in reducing exit site infections (ESI) in CAPD patients, and whether immuno-suppressive therapy, diabetes, disconnect system and Staphylococcus aureus nasal carriage had any bearing on the incidence of ESI. Sixty-six patients having a Tenckhoff catheter placement were randomly allocated into one of three groups; immobilizer, tape and non-immobilized group. The groups were monitored for the incidence of ESI over a total period of 347 patient months. The results show no significant difference in infection rates between the three groups, nor do the factors mentioned have any bearing on ESI rate. Whilst immobilization is important, the ineffectiveness of this device was probably related to its design problem.
Adv Perit Dial 1992
PMID:Does catheter immobilization reduce exit-site infections in CAPD patients? 136 3

The impact of peritonitis on CAPD results was evaluated in 1990 pts (mean age +/- SD:58.4 +/- 14.8 yrs, 55.9% males), treated in 30 centres participating in Italian PD Study Group, during 1980-89, with an overall observation period of 3953 years (mean +/- SD 24.1 +/- 22.3 months). The incidence of peritonitis decreases from 1.21 (1980-84) to 0.48 (1985-89) ep/year (overall:0.68) with a significant (P < 0.001) reduction of the probability of developing the first peritonitis episode (FPE) through the same periods. The probability of developing FPE and the relative risk of peritonitis were significantly lower (P < 0.001) in pts for whom CAPD has been the first treatment (80.1%); on the contrary these parameters did not gain significant difference according to sex, age 65 years, diabetes or cardiovascular disease. As far as the organisms responsible for peritonitis are concerned a significant reduction of S. epid. and an increase of S. aureus, other Gram pos. and Pseudomonas was observed in the second 5-yr periods. Peritonitis episodes caused catheter removal in 8.2% of cases and were associated with catheter infection in 10.8% of cases. Peritonitis accounted for 24.2% of hospitalization causes and for 6.7% and 30.0% of death and of drop-out respectively. The probability of death and drop-out was significantly high (p < 0.001) in pts with a peritonitis incidence > 1 ep/year than in those with < 0.5 ep/year. The probability of drop-out due to peritonitis was not higher in diabetic or older patients.
Adv Perit Dial 1992
PMID:The impact of peritonitis on CAPD results. 136 4

CAPD is considered a risk factor for low turnover bone disease. This was previously attributed to aluminum accumulation. We evaluated by biochemical and histomorphometric parameters (including double tetracycline labelling), 26 patients maintained on CAPD for 12-14 months. Three (11.5%) showed mild hyperparathyroidism, 5 (19.2%) osteitis fibrosa, 3 (11.5%) mixed forms, 4 (15%) osteomalacia and 11 (42.3%) adynamic bone disease. Only one patient with diabetes mellitus showed an aluminum stained bone surface > 10%. Intact PTH serum levels were lower in LTBD (133.2 +/- 128 vs 468.2 +/- 451 pg/ml; p < 0.05). We also evaluated prospectively 11 patients who underwent a bone biopsy at start of dialysis and after 12 months of CAPD treatment. Bone biopsies pre CAPD demonstrated normal-high bone turnover disease in 8/11 (72.7%) and low turnover bone disease in 3/11 (27%). In the follow-up biopsies, 2 patients showed osteitis fibrosa and other two mild forms. Low turnover bone disease was found in 7 patients (3 osteomalacia and 4 adynamic bone disease). We conclude that the predominant bone lesion in our CAPD patients is low turnover bone disease, predominantly adynamic forms, and aluminum does not seem to play a role on its genesis. Low intact PTH serum levels may be a predictor of low turnover bone disease.
Adv Perit Dial 1992
PMID:Low turnover bone disease is the more common form of bone disease in CAPD patients. 136 27

The adequacy of peritoneal dialysis should be defined by clinical outcomes. Studies using multivariate techniques to evaluate the effect of demographic and clinical risk factors on these clinical outcomes showed worse patient survival for age > 60 years, diabetes mellitus, history of cardiovascular disease, black race and prior ESRD therapy. The single study reporting a multivariate analysis of urea kinetics and these baseline prognostic factors on clinical outcome showed serum albumin to be the most powerful predictor of survival. A multicentre study (10 Canadian and 4 US Centres) has enrolled 374 consecutive new peritoneal dialysis patients. The target enrollment is 600 patients. Among these 374 patients are 217 males (58%), 71 patients age > 70 (19%), 106 with diabetic renal disease (28%), 95 with a history of cardiovascular disease (25%) and 60 with serum albumin values < 30 Gm/L (16%). There are 307 white patients (82%) and 26 black patients (7%). The 9 month probabilities were: for patient survival, 96%; for technique survival, 93%; peritonitis-free survival, 68%; exit site infection-free survival, 71%. Final statistical analysis will use multivariate techniques to evaluate the relationships among baseline prognostic factors, nutritional status and clinical outcomes.
Adv Perit Dial 1992
PMID:Canada-USA (CANUSA) multicentre study of peritoneal dialysis adequacy: description of the study population and preliminary results. CANUSA Peritoneal Dialysis Study Group. 136 61

The present study was designed to investigate whether microalbuminuria at the onset of diabetic nephropathy might be partially due to the glycation of serum albumin. It is postulated elsewhere (Ghiggeri et al., Proc. Eur. Dial. Transplant. Assoc. 21 (1984) 633-636) that the glycation of serum albumin and the subsequent cationization may induce microalbuminuria. To investigate whether a relationship exists between the amount of glycated albumin in its cationized form and the development, and progression of diabetic nephropathy, the urinary excretion of glycated albumin was studied in diabetic patients. The diabetic patients (type I and II diabetes) were divided into groups according to their albumin excretion rates: group I diabetics had a normal albumin excretion (n = 30, x = 4.2 mg/12 h); group II diabetes displayed microalbuminuria (n = 17, x = 38.6 mg/12 h); group III diabetics displayed macroalbuminuria (n = 21, x = 582.5 mg/12 h). The fraction of glycated albumin in serum (Glyco Gel Test Kit) was 0.032 in group I, 0.042 in group II, and 0.038 in group III, all these values were significantly higher than the value for the controls (0.014%; n = 17, 2 alpha = 0.001) as measured with the Glyco Gel Test Kit. The concentration of glycated albumin in the urine of the controls and group I was below the detection limit. Urine in group II contained only a glycated albumin fraction of 0.0002 of total albumin, and the fraction for group III was 0.0008. Isoelectric focussing (IEF) and chromato-focussing revealed native albumin with an isoelectric point of 4.7-4.9, and anionic glycated albumin with a pI of 3.0-4.2.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Glycation of serum albumin and its role in renal protein excretion and the development of diabetic nephropathy. 149 58

To determine which members of the health care team are viewed by ESRD patients as the most helpful in giving information and deciding on a dialysis modality, we surveyed 42 outpatients after they toured the dialysis facility. The tour included discussions with a social worker, PD and HD nurses, watching a videotape, and receipt of written materials. Nephrologists referred patients for tours. Multiple responses were accepted. Patients felt that social workers (70%) and nurses (71%) gave the most useful information. Fifty per cent of patients thought the nurse, 43% the social worker, 21% the nephrologist, and 21% family or friend most helpful in deciding on PD versus HD. Twenty-three patients chose PD, 16 chose in-center HD. Patients choosing PD were more likely to be white (20/29 versus 3/10, p less than 0.05) and employed (11/23 versus 3/16 choosing HD, p less than 0.10). Patients choosing PD were also better educated but this was not independent of race. No differences in gender, age, or the presence of diabetes were seen among those choosing PD versus HD. Social workers and nurses are more influential than nephrologists in helping patients select a dialysis modality. PD patient recruitment efforts should focus on social workers' and nurses' input.
Adv Perit Dial 1991
PMID:Patient factors and the influence of nephrologists, social workers, and nurses on patient decisions to choose continuous peritoneal dialysis. 168 Apr 3

Though glucose is universally applied as osmotic agent in CAPD, there is great interest in the use of alternative osmotic agents. Glycerol-containing peritoneal dialysis fluids (G-PDF) have been used in an attempt to minimize the metabolic effects of long-term exposure to glucose, especially in patients with diabetes. Since data were lacking, we studied the effect of G-PDF on peritoneal macrophage (PMO) function. In a randomized cross-over setting eight stable diabetic CAPD patients performed the third and fourth exchange of the day with either G-PDF or with glucose-containing PDF (D-PDF) of comparable osmolality. The next day the patients who had used G-PDF were switched to D-PDF and vice versa. PMO were isolated from the effluents and tested for their phagocytic capacity and chemiluminescence response. No differences were encountered in total and differential white cell counts between G-PDF and D-PDF effluents. PMO phagocytic capacity for both S. epidermidis (SE) and E. coli (EC) was significantly depressed after the instillation of G-PDF as compared to D-PDF (SE: 52 +/- 2.7 vs 69 +/- 5.0%, p less than 0.02, and EC: 44 +/- 5.7 vs 63 +/- 6.7%, p less than 0.02). The same held true for peak chemiluminescence response (5.3 +/- 1.36 vs 7.2 +/- 1.43% of control cells, p less than 0.005). Thus, G-PDF may compromise PMO function in vivo more than D-PDF despite its more favourable metabolic profile as compared to D-PDF for diabetic patients.
Adv Perit Dial 1991
PMID:The effect of glycerol-containing peritoneal dialysis fluid on peritoneal macrophage function in vivo. 168 Apr 14


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