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Erythropoietin (EPO) given subcutaneously (SC) once per week has been successful in the treatment of anemia in continuous ambulatory peritoneal dialysis (CAPD) patients. We have identified a population of CAPD patients that requires EPO administration once per week or less often. To determine if specific variables could be identified that would predict which CAPD patients would require infrequent EPO dosing, we reviewed the charts of all our CAPD patients who were receiving EPO as of 1 June 1992. Patients had to have been on CAPD for 3 months and EPO for 3 months to be considered for analysis. We identified 12 patients who required EPO once per week or less frequently (infrequent EPO) and 9 patients who required EPO more than once per week (frequent EPO). Parameters that were analyzed included age, gender, race, time on CAPD, history of gastrointestinal bleeding, exit-site infection or peritonitis in the last 60 days, diabetes, amount of dialysate instilled per day, and the number of exchanges per day. Laboratory data that were analyzed included hemoglobin, hematocrit, serum iron, total iron-binding capacity, ferritin, blood urea nitrogen (BUN), creatinine, BUN/creatinine ratio, albumin, total protein, parathyroid hormone, and aluminum. Categorical data were analyzed via chi-square, and numerical data were analyzed via the t-test. The infrequent EPO group required only 35% as much EPO as the frequent group to maintain hemoglobin and hematocrit, which were significantly greater. The only parameter that was different between the two groups was age (infrequent EPO 42 +/- 13.2 vs frequent EPO 55.8 +/- 11.9 years, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Adv Perit Dial 1993
PMID:Infrequent dosing of subcutaneous erythropoietin for the treatment of anemia in patients on CAPD. 810 57

This study was performed to evaluate the use of the glucose concentration versus glucose absorption in the dialysate to estimate ultrafiltration efficacy. In 26 patients (16 men, 10 women) on continuous ambulatory peritoneal dialysis, a total of 128 dwells were investigated. Each dwell lasted 5 hours, using 2 L of peritoneal dialysis fluid containing 140 mmol/L glucose. After the dwell, the removed peritoneal dialysis fluid was weighted. The concentrations of creatinine and glucose and the total amount of glucose were analyzed. The mean concentration of dialysate glucose for the whole group after a 5-hour dwell was 38.9 +/- 8.9 (SD) mmol/L. The ultrafiltration volume was inversely correlated to the glucose absorbed (r = -0.59, p = 0.002), but was not significantly correlated to the glucose concentration in the dialysate (r = 0.40, p = 0.057). The ultrafiltration volume was not related to the creatinine concentration in the dialysate or the body weight. The average dialysate glucose did not change during a one-year observation time. Patients with diabetes mellitus had significantly lower glucose absorption than nondiabetics (p = 0.045), and patients with low ultrafiltration efficacy had significantly greater glucose absorption than those with normal and high ultrafiltration (p = 0.038). There was no difference between those who had those who had not suffered from peritonitis. The results indicate that the glucose absorption from the dialysis fluid is the best parameter to calculate the peritoneal ultrafiltration efficacy and not the glucose concentration currently used.
Adv Perit Dial 1993
PMID:Ultrafiltration failure and dialysate glucose in CAPD. 810 64

Using a muscle bath technique the vascular response to KCl, noradrenaline, angiotensin II, acetylcholine, and sodium nitroprusside were evaluated in 13 patients with diabetes mellitus (DM group) and 15 nondiabetic (non-DM group) chronic renal failure patients treated with haemodialysis. There were no differences in age, duration of haemodialysis, blood pressure and the levels of plasma renin activity, noradrenaline, and parathyroid hormone between groups. After informed consent was obtained, a small piece of forearm vein was resected during the blood access surgery. The ring preparation of the blood vessel was sustained in the muscle bath filled with Krebs-Henseleit solution and the isometric tension development was recorded. All drugs produced concentration dependent responses in the ring preparations of both groups. Although there were no significant differences in Emax values for KCl- and angiotensin-II-induced contractions between groups, the value for noradrenaline in the DM group was significantly less than that in the non-DM group. Sodium nitroprusside completely relaxed the ring preparation precontracted by 10(-5) M noradrenaline. However, the response to acetylcholine in the DM group was significantly weaker than that in the non-DM group. These results suggest a reduced vascular response to noradrenaline and acetylcholine in dialysed diabetic renal failure patients, which may relate to the autonomic nervous system dysfunction.
Nephrol Dial Transplant 1994
PMID:Vascular response to vasoactive agents in dialysed patients with chronic renal failure with and without diabetes mellitus. 817 67

In this study we compared the antihypertensive and antiproteinuric efficacies of an angiotensin-converting enzyme inhibitor and of conventional treatment consisting of a beta blocker and a diuretic in 13 patients with biopsy-proven glomerulonephritis and a proteinuria of more than 2 g/24 h. Ten of these 13 patients were normotensive. None had diabetes mellitus. In a randomized cross-over design with two treatment periods of 6 weeks, each preceded by a washout period of 4 weeks, patients were treated with benazepril (20 mg o.d.) and the combination of metoprolol (200 mg o.d.) and chlorthalidone (25 mg o.d.). At the end of the treatment periods with benazepril or metoprolol/chlorthalidone mean arterial pressure was lowered to a similar degree by 7.4 (mean, 95% confidence interval 2.0-12.7) and 9.7 (5.7-13.7) mmHg respectively. Both treatment modalities caused similar reductions in proteinuria, being 3.4 g/24 h (mean, 95% confidence interval 2.1-4.8) on benazepril and 3.2 (1.2-5.1) g/24 h on metoprolol/chlorthalidone. Glomerular filtration rate and renal plasma flow were slightly less during metoprolol/chlorthalidone treatment. Subgroup analysis of normotensive patients gave similar results. In conclusion, in these patients with glomerular disease angiotensin-converting enzyme inhibition was not more effective than the conventional treatment with the combination of a beta blocker and a diuretic in reducing blood pressure and proteinuria. Both treatments reduced proteinuria not only in hypertensive, but also in normotensive patients.
Nephrol Dial Transplant 1993
PMID:Angiotensin-converting enzyme inhibition and the combination of a beta blocker and a diuretic are equally effective in lowering proteinuria in patients with glomerulonephritis. 825 12

In recent years an impressive decrease in the incidence of CAPD-related peritonitis was observed in our centre, from 1.4 in the mid-eighties to 0.4 per patient year in 1991. In order to analyse which factors were most responsible for this decline, the present study was performed. From the start of our CAPD programme in 1982 until September 1991, 100 patients were enrolled. For each patient, time elapsed from catheter insertion until first peritonitis episode was recorded. Outcome was measured as the peritonitis-free interval in days. The following variables have been evaluated: age, gender, type of catheter, type of system, presence of diabetes mellitus, leakage, break-in period, presence of an exit-site infection, and performing surgeon. Data were analysed first by Kaplan-Meier product-limit estimate of survival (peritonitis-free interval). Thereafter Cox proportional hazard analysis was applied to the data, providing a conditional probability of peritonitis at each moment during follow-up, given a certain combination of risk factors. Our results show that the system, in conjunction with the type of catheter, was a decisive factor in the decline of the peritonitis rate in our centre. Patients on the twin-bag system (twin-bag group) showed a significant increase in the peritonitis-free interval in comparison with patients using other systems (non-twin bag group). Among the other variables analysed, only diabetes mellitus appeared to be relatively important. Episodes of culture negative peritonitis were more frequently observed in the twin-bag group, compared to the non-twin bag group. In absolute numbers Staph. non-aureus was the micro-organism most effectively reduced.
Nephrol Dial Transplant 1993
PMID:Major reduction of CAPD peritonitis after the introduction of the twin-bag system. 830 63

The kidney is responsible for a considerable part of the clearance of insulin and C-peptide. Two routes are thought to be involved in the renal extraction of insulin and C-peptide from the circulation: (1) glomerular filtration, and (2) uptake by tubular cells from peritubular capillaries. The aim of the present study was to investigate these processes in non-insulin-dependent diabetes mellitus (NIDDM). For this purpose we measured the renal extraction of inulin, insulin, and C-peptide in 12 NIDDM patients and 16 control subjects during elective heart catheterization. In addition, a 24-h urine sample was obtained from all subjects to assess the fractional clearance of the peptides. The total renal extraction of both insulin and C-peptide exceeded the amount that was extracted by filtration, confirming the supposition that both peptides are cleared by an additional mechanism, most probably peritubular uptake. The peritubular uptake of insulin in the NIDDM group was not significantly different from that in the control subjects, whereas the insulin extraction over the legs was significantly lower in NIDDM than in the controls. The peritubular uptake of C-peptide was significantly lower in NIDDM, while the fractional clearance of C-peptide was significantly higher. The latter indicates that the reabsorption of C-peptide from the luminal side of the tubular cell is impaired in diabetes mellitus. It is therefore concluded that urinary C-peptide excretion is not a reliable index for insulin production in NIDDM.(ABSTRACT TRUNCATED AT 250 WORDS)
Nephrol Dial Transplant 1993
PMID:Renal handling of insulin and C-peptide in patients with non-insulin-dependent diabetes mellitus. 838 33

A total of 1038 adult patients with dialysis-dependent renal failure were treated at this centre between 1981 and 1991. Data on racial origin and primary renal diagnosis have been analysed in order to determine the prevalence of end-stage renal failure (ESRF) and its causes. Compared with Caucasians there was a greater proportion of Asians (P < 0.001) and Blacks (P < 0.001) with ESRF. The relative risk of ESRF in Asians compared with Caucasians was 1.76 (95% CI 1.46-2.10) and for Blacks 1.76 (95% CI 1.39-2.2). Hypertension/renal vascular disease and systemic lupus erythematosus were more frequent causes of ESRF in Blacks than in Caucasians (P < 0.005). Hypertension/vascular disease and tuberculosis were more frequent causes of ESRF in Asians than Caucasians (P < 0.005) respectively. Diabetes mellitus appeared to be more common as a cause of ESRF in Blacks than Asians or Caucasians (0.1 > P > 0.05). Adult polycystic disease was significantly less common in Asians compared to Caucasians and Blacks (P < 0.05). The prevalence of ESRF in Asians and Blacks in the West Midlands appears to be greater than that of Caucasians, mostly as a consequence of hypertension/vascular disease and to a lesser extent of systemic lupus erythematosus in Blacks and of tuberculosis in Asians. If these data are confirmed by prospective study then they have implications for service provision.
Nephrol Dial Transplant 1993
PMID:Increased prevalence of dialysis-dependent renal failure in ethnic minorities in the west Midlands. 838 35

The patient survival (PS) and technique survival (TS) were evaluated in 1990 patients on continuous ambulatory peritoneal dialysis (CAPD) (males: 55.9%, mean age +/- SD: 58.4 +/- 14.8 years), treated in 30 centers participating in the Italian PD Study Group, from 1980 to 1989 (follow-up: 3953 years; mean +/- SD: 2.02 +/- 1.86 years). The total PS was 50.7% at 4 years, compared to 73.3% of patients without clinical high-risk condition (HRC) at the beginning of CAPD. In this group (34.0%) PS was significantly higher (p < 0.001) compared, respectively, to patients with cardiovascular disease (30.5%), diabetes (13.1%), and age > or = 70 years (11.2%). The percentage of death reached the mean value of 11.3% per year without any statistically significant tendency to variation during the follow-up, despite the increased number of patients > or = 65 years old and those with HRC (p < 0.001). Cardiovascular diseases (47.3%) and cachexia (17.8%) were the most frequent causes of death, whereas the mortality due to peritonitis showed a progressive increase in patients with peritonitis incidence 1 ep/year (G4) compared to those with < 0.5 ep/year (G2). Peritonitis (0.68 ep/year) was the most frequent cause of technique failure (30.0%), with clinical complications (18.2%) and peritoneal membrane failure (16.4%) as the second and third causes. The dropout percentage was 8.3% per year with a significant decrease over time (p = 0.012) and a positive correlation with the reduction of peritonitis incidence (p = 0.035). The total TS was 50.1% at 7 years, and it was significantly worse in G4 compared to G2.(ABSTRACT TRUNCATED AT 250 WORDS)
Perit Dial Int 1993
PMID:Ten years of continuous ambulatory peritoneal dialysis: analysis of patient and technique survival. 839 58

A patient-reported checklist was used to assess adequacy of dialysis as measured by 24-hour creatinine clearance in 40 patients on chronic peritoneal dialysis. The checklist consisted of 13 symptoms, each scored from 0-5 with 0 = absent and 5 = severe. The total possible score was 0-65. Patients completed the checklist at the time of 24-hour dialysate and urine collections (in those with residual function) for creatinine clearance (CrCl). Arbitrary grouping by total CrCl in liters/week/1.73 m2 placed patients in one of two groups: those with CrCl < or = 48 L/week (n = 12) and those with CrCl > 48 L/week (n = 28). Patient age, sex, diabetes mellitus, months on peritoneal dialysis, mode of peritoneal dialysis, and hematocrit were not different between the two patient groups. More patients with CrCl > 48 L/week had endogenous renal function (19/28 vs 2/12, p = 0.004). The median total scores for the two patient groups were not significantly different (17 in those with CrCl < or = 48 L/week vs 13.5 in those with CrCl > 48 L/week, p = 0.40). The correlation between total score and CrCl was negative in both patient groups and stronger in those with the lower CrCl (-0.55 vs -0.44). Nausea/vomiting, fatigue, and weakness were the best predictors of CrCl < or = 48 L/week (-0.53, -0.56, -0.49, respectively). The checklist can identify patients with low CrCl and may be useful for following patients over time and altering dialysis prescriptions.
Perit Dial Int 1993
PMID:Patient-reported symptoms and adequacy of dialysis as measured by creatinine clearance. 839 70

This longitudinal study was performed to evaluate the change of total cholesterol, triglycerides, and glucose control in patients with insulin-dependent diabetes mellitus (IDDM) and end-stage renal disease (ESRD) during predialysis (PreD), on continuous ambulatory peritoneal dialysis (CAPD) and after kidney graft. A total of 20 consecutive patients (7 women, 13 men, mean age 42 years) with IDDM and ESRD were studied retrospectively in 1991 during PreD and during CAPD. Twelve were also investigated after obtaining a kidney graft. Insulin was administered intraperitoneally (CAPD period) and subcutaneously (PreD and transplant). The mean values of weight, serum albumin, glycosylated hemoglobin (HbA1c), total cholesterol, and triglycerides were calculated during each period. Patients were age- and sex-matched with a group of healthy controls (Group 1) and with a group of patients with IDDM without nephropathy (Group 2). T-test statistics were used. During CAPD, there were significant decreases in HbA1c (mean 8.1 mmol/L vs 12.1, p = 0.003) and cholesterol (mean 6.1 mmol/L vs 7.1, p = 0.025) compared to PreD. No differences were found between PreD and CAPD stages with regard to weight, serum albumin, or triglycerides. After transplantation an improvement was found in serum albumin compared to PreD and CAPD (mean value 40 g/L vs 34 and 35, p < 0.03), and HbA1c compared to PreD (9.6 mmol/L vs 12.1, p = 0.014), if the pancreas transplanted were included. Patients compared to Group 1 or 2 showed no differences in total cholesterol or triglycerides. HbA1c was higher in patients during PreD than in Group 2.(ABSTRACT TRUNCATED AT 250 WORDS)
Perit Dial Int 1993
PMID:Blood glucose and cholesterol control improved by continuous ambulatory peritoneal dialysis in patients with end-stage renal disease and diabetes mellitus. 839 77


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