Predialysis Glycemic Control is An Independent Predictor of Clinical Outcome in Type Ii Diabetics on Continuous Ambula Tory Peritoneal Dialysis
Chun-Chen YuMai-Szu WuChing-Herng WuChih‐Wei YangJeng‐Yi HuangJenn-Jye HongChun-Yi Fan ChiangMei-Ling LeuChiu‐Ching Huang
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To evaluate the correlation between predialysis glycemic control and clinical outcomes for type II diabetic patients on continuous ambulatory peritoneal dialysis (CAPD).Sixty type II diabetic patients on CAPD were classified into 2 groups according to the status of glycemic control. In group G (good glycemic control), more than 50% of blood glucose determinations were within 3.3-11 mmol/L and the glycosylated hemoglobin (HbA1C) level was within 5-10% at all times. In group P (poor glycemic control), fewer than 50% of blood glucose determinations were within 3.3-11 mmol/L or HbA1C level was above 10% at least once during the follow-up duration. In addition to glycemic control status, predialysis serum albumin, cholesterol levels, residual renal function, peritoneal membrane function, and the modes of glycemic control were also recorded.Dialysis Unit, Department of Nephrology of a single university hospital.From February 1988 to October 1995, 60 type II diabetic patients receiving CAPD for at least 3 months were enrolled.Morbidities before and during the dialysis period, patient survival, and causes of mortality.The patients with good glycemic control had significantly better survival than patients with poor glycemic control (p < 0.01). There was no significant difference in predialysis morbidity between the two groups. No significant differences were observed in patient survival between the patients with serum albumin greater than 30 g/L and those with less than 30 g/L (p = 0.77), with cholesterol levels greater or less than 5.18 mmol/L (p = 0.73), and with different peritoneal membrane solute transport characteristics evaluated by peritoneal equilibration test (p = 0.12). Furthermore, there was no significant difference in survival whether the patients controlled blood sugar by diet or with insulin (p = 0.33). Cardiovascular disease and infection were the major causes of death in both groups. Although good glycemic control predicts better survival, it does not change the pattern of mortality in diabetics maintained on CAPD.Glycemic control before starting dialysis is a predictor of survival for type II diabetics on CAPD. Patients with poor glycemic control predialysis are associated with increased morbidity and shortened survival.Keywords:
Dialysis adequacy
Nephrology
End-stage renal disease affects a large number of patients in Asia. The percentage of patients utilizing PD varies significantly in Asian countries. Continuous ambulatory peritoneal dialysis (CAPD) accounts for about 80% of the dialysis population in Hong Kong. In this review, we address several questions related to adequacy targets in Asians: Are Asians different? Is dialysis adequacy important for Asians? What is the magnitude of the benefit and the optimal dose of dialysis prescription? Is the adequacy target realistic? The current international recommendations, including the Dialysis Outcomes Quality Initiative guidelines, are compared with some of our own data for Asian patients. Our published data on dialysis adequacy, nutrition, residual renal function, and peritoneal membrane transport showed that those factors have a significant impact on the morbidity and mortality of PD patients in Hong Kong. Our results show that solute clearance as measured by Kt/V has a significant impact on the outcome of Asian CAPD patients. Although Chinese PD patients have excellent medium-term patient and technique survival despite an apparently lower Kt/V as compared with the CANUSA standard, that favorable outcome should not prevent nephrologists from providing adequate dialysis to Asian patients. From our own data and analysis, we propose a target Kt/V of 1.9 in Asian CAPD populations. Small-volume dialysis (6 L daily) may be an acceptable compromise in some Asian populations with a smaller body size, especially with residual renal function, given the financial constraints in some developing countries. Dialysis adequacy means more than a Kt/V value; other clinical parameters are equally if not more important. Thus we should also aim at achieving adequate fluid removal and volume homeostasis, blood pressure control, good nutrition, normal acid-base balance, normal mineral metabolism, minimal anemia, and normal lipid metabolism.
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Nephrology
Dialysis adequacy
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Objective To evaluate the impact of pre-dialysis glycemic control on clinical outcomes for type II diabetic patients on continuous ambulatory peritoneal dialysis (CAPO). Materials and Methods One hundred and one type II diabetic patients receiving CAPO for at least 3 months were enrolled in a single institute. The patients were classified into two groups according to status of glycemic control. In the good glycemic control group, more than 50% of blood glucose determinations were within 3.3 11.0 mmol/L and glycosylated hemoglobin (HbA 1 C) levels were within 5% -10% at all times. In the poor glycemic control group, less than 50% of blood glucose determinations were within 3.3 -11.0 mmol/L, or HbA1C levels were above 10% at least 6 months before peritoneal dialysis was started. In addition to glycemic control status, pre-dialysis serum albumin, cholesterol levels, residual renal function, peritoneal membrane function, and modes of glycemic control were also recorded. Results The patients with good glycemic control had significantly better survival than those with poor glycemic control (p < 0.01). There was no significant difference in pre-dialysis morbidity between two groups. No significant differences were observed in patient survival between patients with serum albumin above 30 g/L and those with serum albumin under 30 g/L; between those with cholesterol levels above or below 5.2 mmol/L; and between those with different peritoneal membrane solute transport characteristics as evaluated by a peritoneal equilibration test (PET). Furthermore, there was no significant difference in survival between patients who controlled blood sugar by diet and those who controlled it by insulin. Cardiovascular disease and infection are the major causes of death in both groups. Although good glycemic control predicts better survival, it does not change the pattern of mortality in diabetic patients maintained on CAPO. Conclusions Glycemic control before starting dialysis is a predictor of survival for type II diabetic patients on CAPO. Patients with poor glycemic control predialysis are associated with increased morbidity and shortened survival.
Peritoneal equilibration test
Dialysis adequacy
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The decline of residual renal function (RRF) in peritoneal dialysis (PD) patients was analysed and assessed, and risk factors affecting its decline were identified. Residual glomerular filtration rate (GFR) was calculated from averaging the urea and creatinine clearance by 24-h urine collection, and peritoneal solute removal was evaluated by creatinine clearance calculated from 24-h effluent collection. Both GFR and peritoneal solute removal were chronologically examined in 34 PD patients from the time of initiation, and risk factors associated with rapid GFR decline were investigated. The RRF contributed to 43.1 +/- 17.6% of total (peritoneal and renal) weekly creatinine clearance at 1 month after initiation of PD. Residual GFR, however, declined continuously with time (-0.19 +/- 0.14 mL/min per month), and the reduction rate was high with a higher GFR, higher normalized dietary protein intake, higher urine volume and higher urine protein excretion at the initiation of PD. Other factors related to the rapid decline of GFR were: being older than 60 years of age, automated peritoneal dialysis (APD) rather than continuous ambulatory peritoneal dialysis, mean blood pressure higher than 110 mmHg, and serum human atrial natriuretic peptide level higher being than 60 pg/dL. These data suggest that while RRF plays an important role in the removal of uraemic solute in PD patients, they show a significant decrease over 2 years. The factors related to the rapid decline of GFR corresponded to older age, modality of PD (APD), higher GFR and higher amount of urine protein at initiation, higher dietary protein intake, and inadequate control of hypertension and body fluid volume.
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Objective Despite a lack of strong evidence, automated peritoneal dialysis (APD) is often prescribed on account of an expected better quality of life (QoL) than that expected with continuous ambulatory peritoneal dialysis (CAPD). Our aim was to analyze differences in QoL in patients starting dialysis on APD or on CAPD with a follow-up of 3 years. Methods Adult patients in the prospective NECOSAD cohort who started dialysis on APD or CAPD were included 3 months after the start of dialysis. The Medical Outcomes Survey Short Form 36 [SF-36 (Medical Outcomes Trust and QualityMetric, Lincoln, RI, USA)] and Kidney Disease and Quality of Life Short Form [KDQOL-SF (KDQOL Working Group, Santa Monica, CA, USA)] questionnaires were used to measure QoL. Differences in QoL over time were calculated using linear mixed models. Patients were followed until transplantation, death, or a first switch to any other dialysis modality. Results The clinical and social characteristics of the 64 APD and 486 CAPD patients were slightly different at baseline. In the crude analysis, the pattern of the mental summary score differed between the modalities ( p = 0.03, adjusted p = 0.06), because of a different pattern for role function emotional ( p = 0.03, adjusted p = 0.05). The pattern of the physical summary score was not different between the groups. Scores on dialysis staff encouragement had a different pattern over time ( p = 0.01), because of an in-equality in scores 3 months after the start of dialysis, which disappeared after 18 months on dialysis. Over time, patients on APD scored higher on sexual function. After adjustment for age, sex, glomerular filtration rate, comorbidity, and primary kidney disease, that difference disappeared. This study showed no major differences in QoL on the KDQOL-SF and the SF-36 between the two modalities.
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To evaluate the impact of pre-dialysis glycemic control on clinical outcomes for type II diabetic patients on continuous ambulatory peritoneal dialysis (CAPD).One hundred and one type II diabetic patients receiving CAPD for at least 3 months were enrolled in a single institute. The patients were classified into two groups according to status of glycemic control. In the good glycemic control group, more than 50% of blood glucose determinations were within 3.3-11.0 mmol/L and glycosylated hemoglobin (HbA1C) levels were within 5%-10% at all times. In the poor glycemic control group, less than 50% of blood glucose determinations were within 3.3-11.0 mmol/L, or HbA1C levels were above 10% at least 6 months before peritoneal dialysis was started. In addition to glycemic control status, pre-dialysis serum albumin, cholesterol levels, residual renal function, peritoneal membrane function, and modes of glycemic control were also recorded.The patients with good glycemic control had significantly better survival than those with poor glycemic control (p < 0.01). There was no significant difference in pre-dialysis morbidity between two groups. No significant differences were observed in patient survival between patients with serum albumin above 30 g/L and those with serum albumin under 30 g/L; between those with cholesterol levels above or below 5.2 mmol/L; and between those with different peritoneal membrane solute transport characteristics as evaluated by a peritoneal equilibration test (PET). Furthermore, there was no significant difference in survival between patients who controlled blood sugar by diet and those who controlled it by insulin. Cardiovascular disease and infection are the major causes of death in both groups. Although good glycemic control predicts better survival, it does not change the pattern of mortality in diabetic patients maintained on CAPD.Glycemic control before starting dialysis is a predictor of survival for type II diabetic patients on CAPD. Patients with poor glycemic control predialysis are associated with increased morbidity and shortened survival.
Dialysis adequacy
Peritoneal equilibration test
Serum Albumin
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Objective To investigate the effect of follow-up frequency on the dialysis quality of patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Methods 298 CAPD pa-tients were selected for retrospective analysis from December 2005 to April 2007. All patients were di-vided into two groups according to different follow-up frequency: group A (shorter than 3 months),group B (longer than 3 months). The dialysis quality of the two groups was compared. Results The levels of hemoglobin, albumin and transferrin of group A were (112.19±20.62)mmol/L, (40.45±4.50) retool/L, (2.43±0.29) mmol/L,which were significantly higher than those of group B, (99.63±20.69) mmol/L, (38.01±5.02)mmol/L,(2.29±0.36) mmol/L (P＜0.05). In addition, edema level, life self-care,work capacity, median duration of dialysis, education level and address in group A were significantly different from those of group B (P ＜ 0.05). Conclusion Shortening follow-up frequency plays an im-portsnt role in improving the dialysis quality of CAPD patients.
Key words:
Peritoneal dialysis; Follow-up; Dialysis quality
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BACKGROUND: Automated peritoneal dialysis (APD) has been increasingly used in recent years. Our purpose was to investigate whether the good preservation of residual renal function (RRF) that has been reported in patients on continuous ambulatory peritoneal dialysis (CAPD) is also observed in APD. METHODS: RRF was determined and compared prospectively over 1 year in two groups of peritoneal dialysis (PD) patients: 18 consecutive new patients starting on APD (12 continuous cyclic peritoneal dialysis (CCPD) patients and six nightly intermittent peritoneal dialysis (NIPD) patients) and 18 selected patients who had started on CAPD at the same time and were matched for baseline characteristics. RRF was assessed on normalized creatinine clearance (ml/min/1.73 m2) measured before the start of PD, at 6 months, and at 1 year. Wilcoxon's rank sum test was used to compare differences between the two groups. RESULTS: Creatinine clearance (ClCr) was 6.1 ml/min in the APD group and 6 ml/min in the CAPD group at the start of PD. The monthly rate of ClCr decrease was significantly higher in the APD group: -0.28 ml/min vs -0.1 ml/min (P = 0.04) at 6 months and -0.26 ml/min vs -0.13 ml/min (P = 0.005) at 1 year. RRF decreased at the same rate in patients treated with NIPD or CCPD. The daily instilled volume of 3.86% glucose dialysis solution (l/day) was higher in APD patients than in CAPD patients: 2.5 vs 0 at 6 months and 1 year but there was no significant difference in ultrafiltration rate (l/day) between APD and CAPD patients at these timepoints: 0.53 vs 0.6 and 0.88 vs 0.7 respectively. There was no difference between the two groups in body weight and blood pressure, which remained stable in both groups throughout the study period. CONCLUSIONS: RRF declined rapidly in APD patients whereas it was well preserved in CAPD patients. This may be explained by the less stable fluid and osmotic load together with the intermittent nature of APD and the larger use of hypertonic dialysate. RRF should be closely monitored in APD patients in order to adjust PD prescriptions and maintain adequacy.
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Peritoneal equilibration test
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Objective To investigate the effect of different dialysate on residual renal function and dialysis adequacy on peritoneal dialysis patients.Methods Routinely follow-up patients who had peritoneal dialysis catheter implantation from Jan 2008 to Dec 2009 were enrolled in this study.They were divided into two groups by the imported and domestic dialysate.Residual renal function,dialysis adequacy and transport type of peritoneum were collected and compared between two groups.Results There were no significant difference between two groups in residual urine volume,glomerular filtration rate,weekly KT/V,weekly creatinine clearance rate(Ccr),dialysate to plasma ratios of creatinine at 4h and net ultrafiltration.Conclusion Domestic dialysate is equivalent to imported dialysate in clearance of small molecular solute and water,effect on renal residual function and peritoneal transport function.Hypernatremia were not observed in domestic dialysate group.
Dialysis adequacy
Residual volume
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ObjectiveTo compare between dialysis modalities and their effect on anemia control, chronic kidney disease mineral bone disease (CKD-MBD) control, dialysis adequacy, and dialysis complication on end-stage renal disease (ESRD) patients.BackgroundHemodialysis (HD) and peritoneal dialysis (PD) are dialysis modalities for ESRD patients that have its own effect on patients. Many publications studied the modality effect on ESRD patients, but in Egypt few data was reported about these items.Patients and methodsThis cross-sectional study was carried out in January 2017 on 82 patients with ESRD maintained on HD and 21 patients with ESRD on PD. HD patients were collected randomly from a pool of HD patients attending regular HD in the Nephrology and Dialysis Department of Damanhour Medical National Institute. The PD patients were collected from the Nephrology and Dialysis Department of Damanhour Medical National Institute (16 patients) and Nephrology and Dialysis Department of New Mansura General Hospital (International) (five patients). A comparison between the two groups regarding anemia control, CKD-MBD, dialysis adequacy, and dialysis complication was performed.ResultsThe PD group was better regarding the target levels of intact parathyroid hormone than HD (61 and 34%, respectively) (P = 0.038) and in the achievement of target Kt/V (90 and 48%, respectively) (P = 0.001). There was no significant difference regarding anemia control or complications.ConclusionPD has a better effect on CKD-MBD and it is easy for the PD patients to achieve adequacy than the HD patients. PD should have more chance as an RRT for the ESRD patients in Egypt.
Nephrology
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