Miscellaneous

Theobald, S.—Reflex Aural Neuroses from Eye-strain. " Journ. Amer. Med. Assoc," July 10, 1909. The author has observed three distinct varieties of tinnitus due to eye-strain, the more usual or vascular type, the relatively low-pitched whirling or fluttering sound caused by irregular contractions of the tensor tympani, and the high-pitched, almost musical, intermittent tinkling produced by contractions of the stapedius. The evidence in favour of the ocular origin of the aural sensations mentioned is their disappearance after the relief of the eye-strain, their greater intensity when the eve-strain is most troublesome, or their appearance or aggravation by use of the eyes. The ocular fault most often present is astigmatism. The tinnitus is probably explained by vaso-motor disturbance of the intralabyrinthine vessels. Macleod Yearsley.

Objectives: CA125 is the most known effluent marker in peritoneal dialysis (PD) and reflects the mesothelial cell mass of the peritoneal membrane. A decline is observed with duration on PD. An association with peritoneal transport parameters is present in short-term PD. In this study we aimed to investigate effluent CA125 as a predictor of technique survival within the first year of PD treatment and before discontinuation of PD treatment.
Methods: This case-control study in the NECOSAD cohort consisted of PD patients that switched to hemodialysis (HD) and patients that stayed on PD during follow-up. Repeated measurements of effluent CA125 were examined at different time intervals after commencing PD and before transfer to HD. To determine the predictive value of CA125 a logistic regression analysis was executed. The analyses were adjusted for age, gender, primary kidney disease and Davies comorbidity score. A linear mixed model was applied to estimate the difference in time course between cases and controls.
Results: Seventy-one patients were transferred to HD and matched to an equal amount of patients that continued PD treatment. Baseline demographics of patients were similar except for PD modality, which was 80% in the cases and 94% in the controls (p=0.005). At 3 months, effluent CA125 differed significantly between cases and controls (p=0.05). However, crude OR 1.03 (95% CI: 0.99-1.07) and adjusted OR 1.03 (95% CI: 0.99-1.07) were nonsignificant. Higher risks were present in effluent CA125 concentrations when measured 24 months prior to technique failure (crude and adjusted OR: 1.03, 95% CI 1.00-1.05) or 18 months (crude OR: 1.02, 95% CI 1.00-1.05; adjusted OR: 1.03 95% CI 1.00-1.05). No difference in time course was detected.
Conclusions: Currently, it is likely that effluent CA125 is able to predict technique survival. However, to determine the precise predictive value additional analyses are required based on various cut-off values of effluent CA125.

Endometrial Carcinoma after Treatment with Tamoxifen in a Patient with Sclerosing Encapsulating Peritonitis
Objectives: Sclerosing encapsulating peritonitis (SEP) is a serious complication in patients treated with peritoneal dialysis (PD). It is characterized by a progressive thickening and sclerosis of peritoneal membrane that compromise bowel motility and function. Numerous case reports suggested that treatment with tamoxifen may be beneficial for treatment of SEP. However, tamoxifen may induce development of numerous serious side-effects.
Methods: We present the first documented case of endometrial carcinoma in a patient with SEP treated with tamoxifen.
Results: Fifty-year-old female with end-stage renal disease due to chronic glomerulonephritis without biopsy has started with renal replacement therapy in the 1987. After two years of haemodialysis she received kidney allograft. In the 1994, after allograft failure she had started with peritoneal dialysis. In 2004 an unsuccessful attempt of kidney transplantation was performed while she lost her graft due to renal artery thrombosis. She had continued with PD. In the 2009 during the pretransplant evaluation, SEP was discovered on computed tomography. Catheter was removed and she had started treatment with haemodialysis. She had received steroids and tamoxifen for treatment of SEP. In May 2011 she was admitted to gynecology because of vaginal bleeding. Curettage revealed secretory type of endometrial adenocarcinoma. There were no cancer cells in dialysate. Due to her overall condition surgery was not performed and she received local irradiation (total of 64 Gy in three doses). Tamoxifen was excluded from the therapy. After 12 months of follow up her overall condition is good without symptoms of intestinal obstruction. She has currently been treated with everolimus.
Conclusions: Peritoneal dialysis patients should be carefully monitored for development of peritoneal membrane thickening. Long-term PD should be avoided. Treatment with tamoxifen may be useful. However, this case demonstrates that patients with SEP treated with tamoxifen should be in regular gynecological follow-up due to potential development of endometrial adenocarcinoma.

Diagnosis, Treatment, and Outcome of 13 Patients with Sclerosing Encapsulating Peritonitis
Objectives: Sclerosing encapsulating peritonitis (SEP) is rare and dramatic complication of peritoneal dialysis (PD). Treatment options include intestinal enterolysis, immunosuppressive treatment and total parenteral nutrition with varying success.
Methods: This report review our experience in diagnosis and treatment of patients with SEP. Clinical characteristics, risk factors, treatment modality and outcome were recorded.
Results: Out 550 patients who entered our peritoneal dialysis program until December 2011, 13 patients developed SEP (2.3%). Male-to-female ratio was 5:8 with the mean age of 50 (range 20 to 72) years. All patients were treated with PD for at least 6 years at the time of SEP diagnosis, with seven of them on PD longer than 10 years. Clinical presentation of SEP included symptoms suggestive of intestinal obstruction in four patients, bloody ascites after transfer to hemodialysis for ultrafiltration failure in two patients, and after evaluation of ascites after renal transplantation in two patients, radiological signs of peritoneal calcifications during computed tomography examination in three patients, perforation of appendix in one patient and perforation of ileum in one patient. Four patients were diagnosed with SEP after renal transplantation. Everolimus has been used in 4 patients. Surgical exploration was performed in 4 patients. All patients were treated with corticosteroids, and three received tamoxifen which was discontinued in one patient after 2 months because of the liver damage, in one patient because of the allergic reaction, and in a female patient who developed endometrial cancer. Six patients died. Causes of death included cardiac arrhythmia in one patient, sepsis in 4 patients and intracranial bleeding in one patient.
Conclusion: SEP is a life-threatening complication of PD. The systemic nature of inflammation should be considered what supports the role of immunosuppressive drugs in treatment of this severe condition.

Influence of the End-stage Disease-specific Unit in Choice Peritoneal Dialysis as First Renal Replacement Therapy
Objective: To evaluate the influence of ESRD-specific unit in the election of type of chronic RRT.
Subjects and methods: Retrospective observational study where all incident patients on RRT between 2007 and 2011 in our Spanish province were included. We analyzed age, sex, diabetes condition, modified Charlson´s index adjusted for age, etiology of ESDR, initial modality of RRT, planned versus nonplanned dialysis starting, hospitalization at the beginning of RRT and during the first month, and the origin of the patients (unknown, ERSD-specific unit or general nephrology care).
Results: 244 patients started RRT in our hospital, 161 males (66%) and 102 diabetics (41.8%). Their medium age was 65±15 years and their medium Charlson's index was 6.9±2.7. The most prevalent etiology of ESDR was diabetes mellitus (36.5%) and then glomerular diseases (21.3%), vascular diseases (15.2%) and tubulointerstitial nephropathies (11%). 56 patients started PD (23%) and 188 hemodialysis (77%). Their origin was ESRD-specific unit in 178 cases (73%) and non-ESRD-specific unit (23%). Data comparing both groups are shown in the Table. Conclusions: More patients have a planned start dialysis and chose PD when they have had predialysis cares in ESRD-specific unit. These specific cares achieve to decrease hospitalization at the time of commencing dialysis and reduce their costs. Patients came from ESRD-specific unit have more comorbility without differences in their age, and more diabetes condition.

The Use of Cloxacillin or Cefazolin in Treatment of Continuous Ambulatory Peritoneal Dialysis (CAPD)-related Peritonitis
Introduction: First generation cephalosporin such as Cefazolin is the recommended first line gram positive coverage for CAPD-related peritonitis by ISPD guidelines. Since Cefazolin is not readily available in the local setting, Cloxacillin is used instead. However, there is limited data regarding the stability of Cloxacillin in peritoneal dialysis solutions. Therefore, there is some concern about the effectiveness of Cloxacillin in the treatment of CAPD-related peritonitis.
Objectives: This study aimed to compare the outcome between the use of intraperitoneal (IP) Cloxacillin and IP Cefazolin in the treatment of CAPDrelated peritonitis, to identify the bacterial aetiology, and to assess the outcome of CAPD-related peritonitis.
Method: This study involved all CAPD patients with confirmed diagnosis of peritonitis in 2011. A self-developed audit form was designed to facilitate data collection.
Results: In 2011, there were 49 peritonitis cases reported. 7 cases were excluded from this study because the first line antibiotic used was not Cloxacillin or Cefazolin. Out of these 42 cases, 20 cases were treated with Cloxacillin and 22 cases were treated with Cefazolin. 10 cases (50%) in the Cloxacillin arm and 10 cases (40.9%) in the Cefazolin arm were converted to second line antibiotic due to unresolved peritonitis. However, the higher percentage of conversion to second line antibiotic in the Cloxacillin arm was not statistically significant when compared to the Cefazolin arm (χ2=0.349; p=0.554). Among 21 cases of culturepositive peritonitis, most cases were caused by Pseudomonas aeruginosa (n=4; 9.5%), followed by equal number of cases caused by Staphylococcus aureus, coagulase-negative Staphylococcus and methicillin-resistant Staphylococcus aureus (MRSA) (n=3; 7.1%). 37 cases (88.1%) resolved with antibiotic treatment alone whereas 5 cases (11.9%) resulted in Tenckhoff catheter removal.
Conclusion: From our data, it appears that IP Cloxacillin is as effective as IP Cefazolin and may be used as an alternative for treatment of CAPDrelated peritonitis.

A Proposal for an Emergency Method in Warming CAPD Bags
Objectives: Disaster strikes when you least expect it. In case of power outages, a CAPD bag warmer never works. Lifeline will be restored in a few days in most cases, but the dialysis of sufferers should be better to be kept on. Some report that disposable heat pads do work in warming bags, but it takes approximately 15 hours with 4 pads and approximately 2 hours with 8 pads. This method should be discussed further from the viewpoint of short supply and bulky waste at the stricken area. We focused on desiccant made of calcium oxide as a heat pad, and report its advantages and problem that we should overcome through the experiment.
Methods: All experimental goods are purchased on the market. Water was infused with syringe into desiccant bags and these were inserted between two compartments of a CAPD bag. Thermometers were placed on the surface of the bag and the temperatures were continuously monitored. After equilibrium was completed, two compartments were connected.
Result: After water injection, desiccant immediately began to react and vaporize. Exothermic reaction was completed and the temperatures were equilibrated within 30 minutes. Rise in temperature depended on amount of desiccants.
Conclusion: CaO desiccants saved time and trouble. Furthermore, produced slaked lime also can be used in disinfectant material. But there may be some troubles in handling and damage to the bag. Only in emergency situation, it may be done or we must verify this method further. Chang T-H., Nishihira M., Kikumura T., Nagayama K., Turayama T., Kouchi M., Yonaha T., Shiohira Y. Dept. of nephrology, Tomishiro Central Hospital, Tomishiro, Japan.

Home Visit Program: Cornerstone of Our Unique PD Program
Introduction: We are the main referral PD center in Bangkok. The rapidly increasing number of PD patients, the wide range of initial uremic condition, the limited family/social support, and financial constraint in some cases, are some examples of the challenging issues.
Method and results: Our PD center set a home visit program regularly. HV team will make the first visit after the training completed, then HV team will make subsequent visit every 3-4 months. The content in routine visit is observation of the area and the technique for exchange procedure and hand-washing, the storage quality of peritoneal dialysis solution and erythropoietin. Compliance of our patients can be assessed by our HV team too. We bring out this dataset from our routine HV database. We divide our data into 4 groups (30 cases per group) by interval between first HV and the other HV. So the first, second, third and fourth group is 3-, 6-, 12-and 18-month intervals. This data show that, comparing between 4 groups, there are minor changes in quality of area of exchange procedure and PD solution storage as shown in the table. Although the change is much more observed in Group D compare to other group.
Our regular HV program can help PD team to detect the problem earlier before it results in bad outcome.
Conclusion: In a unique situation which we recruit all ESRD patients from about 25 hospitals in Bangkok to support PD First Policy. We cannot modify the initial patient's condition but we can early detect any important changes and make an appropriate intervention along the course of PD program. Home visit program for our center is the cornerstone.

Quality of Storage
Area ( Introduction: In this Thailand's worst flood, we realize that both hemodialysis and peritoneal dialysis patients were vulnerable to any form of morbidity and mortality.
Results: First week -We started to manage 3 things. 1. Supply: PD solution was prescribed and sent to every patient's house before the usual due date. And our center also increased PD solution stock too. Dressing sets were prescribed and distributed to all patients. 2. Procedure: we distributed our new guideline for our patients which the content comprised of the space for exchange procedure in case of they need to move to the shelter area, the modified hand washing technique in case of shortage of tap water and how to manage the drain bag. Additionally, we gave the suggestion how to treat the tap water in case of the quality of the tap water is not good. 3. Communication: Every morning our team will have a meeting to set up a plan and the messages will be communicated to our patients. Second week -The flooding situation became worse. We decided to provide three options for our patients. 1. Move to other provinces. 2. Move to 'Banphaeo PD Center Shelter'. 3. Guideline for patients who decide not to move. If our patients decided to move to other provinces, we will inform PD case manager at the destination and give contact data to our patients in case of emergency problem. And we suggest them to MMS the photo of exchange solution and hand washing area to us. If our patients decided not to move out, we will contact them regularly, especially who live in vulnerable area. Third to Fourth weeks -At the end of second week, we decided to set 'Banphaeo PD Center Shelter'. This specific shelter area provided the basic need for normal living and suitable space for PD patients to perform the exchange procedure and exit-site care. Conclusion: A specific care plan for specific disaster need to be prepared. PD patients seem to maintain their dialysis procedures normally if PD care team takes a leading role in fighting against any form of disaster.

The Brazilian Peritioneal Dialysis Multicentric Study (BRAZPD II): Characterization of the Cohort
Introduction/Objective: This is an update and final description of the Brazilian Peritoneal Dialysis Multicenter Study II (BRAZPD II), a continuation of the large study launched in the year of 2004 and finalized in February 2011. This analysis aims to describe the main characteristics of this cohort.
Methods: This was an observational cohort study of 11,183 patients from 134 Brazilian centers recruited from December 2004 to January 2011. All centers reported monthly through a central web-based software program and the data was periodically extracted to a database. After initial baseline retrospective data collection, all patients were followed prospectively monthly until they dropped out of the PD program, or were censored at the end of the study (February, 2011).
Results: The mean follow-up was 16.6 months, ranging from 1 to 71 months. Mean age was 55±21 years, with 52% females and 63% Caucasians. Diabetic nephropathy was the main cause of renal disease (35%), followed by hypertension (17%) and glomerulopathies (10%). With respect to comorbidities, diabetes was presented in 36%, left ventricular hypertrophy in 32%, and ischemic heart disease in 21%. The estimated overall peritonitis rate was 1 episode per 41 patient-months (most frequently due to gram-positive organisms). The total dropout rate was 41%, mainly due to death (49% of dropouts). The gross mortality was 20% per year and the main causes of mortality were cardiovascular disease (36%) followed by infection (28%).
Conclusion: This data describes the main characteristics of this large national, long-term clinical study. The ongoing analysis of this PD database will further provide important information related to PD practice and predictors of outcome, particularly applicable to developing countries.

Peritoneal Dialysis in Saudi Arabia: a Single Center Experience
PD is growing in Saudi Arabia and currently approaching 14.5% of the total ESRD population. Many factors have contributed to this growth, among them more PD trained nephrologists, public awareness and the Saudi Society of Nephrology efforts in developing the therapy in the Kingdom. The CAPD program at the Dept of Nephrology of the Security Forces Hospital in Riyadh was initiated in 1994 and APD in 2001. During this period, 638 ESRD patients have been treated with either APD (n=260) with average treatment duration of 40.6 months (range 6-107 months) or CAPD (n=293) with average treatment duration of 36.5 months (range 7-91 months. Peritonitis rates have improved from 1 episode/10.8 pt months in 1994 to 1 episode/22.9 pt months in 1999 and 1 episode/32 pt months in 2011. The most common peritonitis causative microorganisms were St. aureus and Pseudomonas species, whereas no growth occurred in 20.5 % of the PD effluent cultures. Regarding exit-site infection rates, they have improved from 1 episode/18.1 pt months in 2003 to 1 episode/36 pt months in 2011 and non-MRSA St. aureus was the most predominant causative microorganism (52.2%). Dialysis delivery has been consistent with an average Kt/V=2.2 and weekly creatinine clearance of 76.3 liters/week. Main reasons for drop-out have been death (16%), kidney transplant (6.8%) and PD-related complications (6%). Mortality has improved along the years and in 2011 it was of 5.7%. The most important causes of death were non-PD related sepsis (23.6%) and PD-related sepsis (11.1%). An important and interesting information was that almost half of the deaths occurred at home (46%). More than half of the patients followed up in this clinic have started PD. Our results regarding peritonitis and exit-site infection rates are similar to those from other countries and our pre-dialysis clinics have shown to be a big driver in the PD growth in our Department. In conclusion, our experience with use of PD as a RRT has been successful and in line with the results obtained not only in Saudi Arabia but also with the positive PD results from different parts of the world. Divino J., Alharbi A., Kechred M., Azhari A., Naje F., Almohaya S., Shetia S. Department of Internal Medicine, Nephrology Division, Security Forces Hospital, Riyadh, Saudi Arabia.

Day-of-Week Mortality, Occurrence of Peritonitis and Transfer to Hemodialysis (HD) in Patients on Peritoneal Dialysis (PD) in the RDPLF Database
Purpose: Recent publications have indicated that mortality of hemodialysis patients is the highest on the first day of their weekly schedule. This is probably due to the discontinuous character of HD. What about PD, a continuous dialysis mode?
Methods: We looked at the recorded deaths of all patients aged ≥18 from metropolitan France and Belgium entered in the database of the Frenchspeaking Registry of Peritoneal Dialysis (RDPLF) between 01/01/2007 and 31/12/2011 and extracted the day-of-week they occurred; this was also done for peritonitis; in addition, we determined the day-of-week patients were transferred to HD.
Results: Day-of-week deaths: Monday: 434, Tuesday: 419, Wednesday: 454, Thursday: 436, Friday: 383, Saturday: 379, Sunday: 432. These nonsignificantly different numbers represented from 11.9 to 14.5 % of all deaths, with no significant variation between the years observed. The main causes of death (in % of all deaths) were: non-PD related (66.2 to 70.2 %), coronary artery disease (14.5 to 17.7 %), peritonitis (2.7 to 5.6 %), malnutrition (2.7 to 6.6 %) and cancer (3.0 to 6.0 %), without a day-of-week effect. As to peritonitis, its occurrence was significantly (Spearman's rank coefficient=-0.785, p<.05) different along the week (ranging from 328 to 836 cases or 13.0 % to 33.0 % relative to the mean number of treated patients per year, 2533). Finally, among 1876 transfers to HD mainly caused by peritonitis, underdialysis and catheter dysfunction, 88 (4.7 %) were decided on a Saturday, and 165 (8.8%) on a Friday, while on the other days, there were 304 to 348. No difference was observed between France and Belgium.
Conclusion: In the largest European PD database, there was a dayof-week effect on the occurrence (or reporting?) of peritonitis, as well as transfer to hemodialysis, but none in terms of mortality.

Drop-out Rate from a Continuous Ambulatory Peritoneal Dialysis (CAPD) Program over a Five-year Period
Introduction: There has been a steady increase in the uptake of peritoneal dialysis (PD) in Malaysia but 42% of patients drop out due to peritonitis. It is well-recognized that membrane failure occurs after a prolonged period of PD.
Objectives: To evaluate the reasons for drop out on our CAPD program. Methods: All CAPD patients transferring into/out of our PD program are audited on a monthly basis. Data was collected on a 5-year period including PD adequacy, transporter status and reason for drop-out as deemed by a nephrologist.
Results: Eighty-one patients dropped out of PD. Demographics are shown on the Table. Peritonitis and membrane failure were the leading causes for drop out when censored for death and transplantation (42.4% and 13.5%, respectively). Five-year mortality rate was as low as 17.2%. Only 16% of our patients had no residual renal function and 78.3% had a Kt/V >1.7. 43.5% of our patients were high/high average transporters.
Conclusion: Peritonitis is the leading cause of drop out from PD in our cohort. Reassuringly, our mortality rate on PD is relatively low compared to national data. Demographics

Encapsulating Peritoneal Sclerosis (EPS): the Abdominal Cocoon
Introduction: Encapsulating peritoneal sclerosis (EPS) is a rare and serious complication of peritoneal dialysis.
Objective: To determine the incidence, clinical presentation, risk factors contributing to EPS and its outcomes at our center.
Results: A total of 4/176 patients developed EPS over a 10 year period (incidence -0.23%). Their mean age and duration of PD were 45±9.13 years and 72.29±10.36 months, respectively. Mean duration at development of EPS after switching dialysis modality (all on hemodialysis) was 8.99±6.87 months. The mean duration since EPS diagnosed was 9.7±10.23 months. The characteristics of the patients are demonstrated in the table.
Conclusion: In all patients, EPS was associated with prolonged duration on PD and the use of hypertonic glucose solution which should be avoided.

Icodextrin and Acute Pancreatitis in CAPD Patients
Background: Adult patients on PD have 15 times increased risk of developing acute pancreatitis (AP), compared to general population. In literature, role of icodextrin in developing acute pancreatitis is scanty.
Objectives: 1) To study the incidence of acute pancreatitis in patients on CAPD. 2) To assess the role of icodextrin in risk for developing pancreatitis in CAPD patients.
Methods: CAPD patients with minimum 06 months on PD from Jan 2006 to July 2011 were included. Patients with past history of peritonitis, gall stones, on long-term steroids and alcoholics were excluded. Data analysed using SPSS software.
Results: Of 192 consecutive CAPD patients followed up, 52 who were on icodextrin, in addition to glucose solution, were included. Total of 6 patients developed pancreatitis, all of whom were males and 5 were on icodextrin. The incidence of pancreatitis in this cohort was 0.78 /100 treatment years and overall 3.1%. One patient was on only glucose based solutions. Mean duration of time on treatment before start of icodextrin was 30.4±16.22 months and after icodextrin was16.6±5.3 months. Incidence of pancreatitis after addition of icodextrin to treatment was 9.6/100 treatment years. The odds ratio of developing pancreatitis while on icodextrin was 1.89. Mean time to development of pancreatitis after start of icodextrin was 5.6±1.2 months. Two of the 5 patients on icodextrin based treatment had recurrent pancreatitis. While 5 patients recovered completely with conservative management, 1 succumbed to pancreatitis Conclusions: 1. Incidence of acute pancreatitis in PD population was 0.78/100 patient years, 24 times higher than Indian general population. 2. Patients added on icodextrin were at a significantly higher risk of pancreatitis implying a strong suspicion of cause effect relationship between the two.

A Review of Assisted PD Program and Self-care PD Program in Hospital Serdang
Peritoneal dialysis (PD) remains a viable treatment option for End Stage Renal Disease (ESRD) patients. Self-care PD is often offered to those fit ESRD patients and the assistance allows elderly or disabled persons with barriers to self-care peritoneal dialysis (PD). A retrospective review was conducted to analyze the assisted PD and the self-care PD program. A total of 219 patients were enrolled in our PD program since 2006 till December 2011 involving 98 (45%) male and 121 (55%) female with mean age of 51.00±15.02 years. Among this, 132 (60%) were self-care PD patients and 87 (40%) patients required assistance. The mean age for self-care PD patients were younger (46.08±12.96) compared to the assisted group (63.13±11.91). The reasons for assistance were reported as disability (83%), illiterate (3%), and poor technique (14%). The assistants were the spouse (47%), children (37%), maid (8%) and others (8%). Comorbidities such as diabetes, hypertension and cardiovascular disease were similar among both groups. The assisted PD group recorded a lower kt/V of 1.5±0.93 compared to self care PD patients, 1.82±0.82. However, there were no significant differences between the biochemical profiles such as albumin, hemoglobin, potassium and phosphate level. In term of peritonitis rate, the self-care patients (46%) were doing better as compared to assisted group (54%) in a total of 124 peritonitis episodes. A higher mortality was reported in the assisted group (58%) compared to self-care PD cohort (42%). In conclusion, the assisted cohort demonstrated poor outcome as they were elderly, had lower kt/V, with higher rate of peritonitis thus causing higher risk of mortality. Further study should be done in the future to determine better selection of patients or the assistants to improve the outcome of this group of patients. This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at marketing@multi-med.com S148 ABSTRACTS OF THE 14TH CONGRESS OF THE ISPD September 2012 -Vol. 32, SUppl. 3 PDI miscellAneous

Relationships Between Physical Function Tests and Nutritional Status of Peritoneal Dialysis Patients from Two Hospitals in Kuala Lumpur, Malaysia
Objectives: Peritoneal dialysis (PD) patients are at risk of malnutrition and protein-energy wasting (PEW) resulting in skeletal muscle atrophy. The aim of this study was to identify the relationships between physical function tests and nutritional status of PD patients.
Methods: Body composition measurement was performed for each patient before dialysis. Demographic data as well as International Physical Activity Questionnaire (IPAQ), Subjective Global Assessment (SGA), Malnutrition-Inflammation Score (MIS) and 24-hour diet recall data were collected from patients. Laboratory data were obtained retrospectively. Physical function (PF) tests included 2 endurance tests (high stool and short stool tests), 2 strength tests (hand grip [HG] and back-leg chest dynamometry (BLC) and balance tests (tandem walk test, single leg stance test, timed up and go (TUG) test and chair stand test). Spearman/ Pearson correlations were used for continuous data and Mann-Whitney test was used for categorical data. Multiple linear regression analysis was also performed.
Results: 28 malnourished (SGA score<3) patients (13 men and 15 women) with a mean (± SD) age of 42.28±14.94 years and dialysis duration of 4.36±3.4 years were enrolled. MIS significantly correlated with tandem walk test categories (p<0.05). Mid arm muscle area (MAMA) significantly correlated with HG (p=0.01), BLC (p=0.001) and Tandem walk forward (p=0.04). C-reactive protein (CRP) significantly correlated with TUG (p=0.01), IPAQ (p=0.02) and HG (p=0.03). Body composition, serum albumin, total energy and protein intake were not correlated with any of the parameters (p>0.05). Regression analysis revealed a significant relationship between SGA and IPAQ (p=0.04), Tandem walk forward (p=0.01) and backward (p=0.01) while MIS was not significantly correlated with any of the tests.

What Is the Expected Solute Clearance with Single Exchange of Icodextrin?
Objective: To determine the solute clearance of single icodextrin exchange in peritoneal dialysis patients.
Materials and Methods: We have a protocol of incremental peritoneal dialysis in patients with residual renal function. Our protocol for incremental dialysis is to offer all adult end stage renal failure patients opting for peritoneal dialysis (PD) as renal replacement therapy and having residual renal function, urinary KT/V of about 1.0, single nocturnal icodextrin exchange ('ico-alone') as initial treatment. Adequacy of dialysis was calculated at 1 month, 3 month, 6 month and then 6 monthly. Patients were shifted to conventional peritoneal dialysis of 3/4 exchanges if short of adequacy or if clinically indicated. Adequacy of all patients on 'ico-alone' incremental dialysis protocol was analyzed. Mean solute clearance from icodextrin dialysis was determined from the adequacy tests. Median period on 'ico-alone' was also determined.
Results: A total of 13 patients satisfied the criteria and were initiated on 'ico-alone' incremental dialysis protocol. Mean age was 58±9.4 years with 38.4% males and 69.2% diabetics. Median period on 'ico-alone' protocol was 9.6 months and median 'actuarial' technique survival was 15.01 months (Kaplan Meier survival). Mean total KT/V at 1 month, at last follow up and of all the adequacies available were 1.7±0.4, 1.5±0.4 and 1.66±0.5, respectively. Mean dialysate (icodextrin) KT/V at 1 month, at last follow-up and of all adequacies available were 0.6±0.3 (n=13), 0.6±0.1 (13) and 0.56±0.2 (n=41), respectively. As these patients were only on single exchange, they truly represent the solute clearance of icodextrin without influence of glucose dialysate in conventional PD regime. There was no change in icodextrin solute clearance over the study period as shown by the adequacy tests and the conversion to conventional dialysis was due to drop in residual renal clearance rather than change in icodextrin clearance over the period.
Conclusion: Single exchange of icodextrin can give a clearance of about 0.6 KT/V.

Hemolytic Uraemic Syndrome in Children: Typical and Atypical
Context: Hemolytic Uremic Syndrome (HUS) is one of the main causes of acute renal failure in children. It is a multifaceted disease, characterized by microangiopathic hemolytic anemia and thrombocytopenia. It can often affect multiple organ systems including the central nervous system. Depending on the clinical presentation, HUS can be classified as typical or atypical.
Objectives: Two case studies will be presented that will highlight the differences between typical and atypical HUS. Discussion in this paper will include the management of two cases of HUS in children admitted to a pediatric renal unit. An eight-year-old girl who presented with typical HUS was treated with peritoneal dialysis and plasma exchange. A five-year-old boy who presented with atypical HUS was treated with plasma exchange. These complex case studies will demonstrate the strategic medical, nursing and allied health management of these children.
Key messages: The importance of identifying the differences in presentation and management of typical and atypical HUS. Typical HUS, which is the most common form, is associated with a prodromal episode of diarrhea that is often bloody and associated with Escherichia Coli. Atypical HUS is a heterogeneous disorder where there is an absence of the diarrheal prodrome. Treatment and prognosis is dependent on the type of HUS. Typical HUS starts with severe symptoms but the atypical form has long term consequences Implications for clinical practice: It is important to ascertain the correct diagnosis early and initiate appropriate therapy accordingly. HUS is a syndrome that has seen several important advances in relation to therapeutic approaches. Jeloka T., Sanwaria P., Periera A., Dey A. Aditya Birla Memorial Hospital, Pune, India.
Jeyakumar Y. Monash Childrens at Southern Health, Monash, Australia.

Oral and Salivary Changes in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis
Objective: To compare oral health status, radiographic feature, and biochemical composition of saliva between the patients undergoing CAPD and age-and sex-matched healthy control.
Methods: Thirty-three CAPD and 37 age-and sex-matched healthy volunteers were enrolled. The questionnaires, oral radiography, and intraoral examination, including number of decayed teeth, filled teeth, missing teeth, plaque index, gingival index, calculus index, and oral hygiene index were performed in both groups. Two views of oral radiology, comprising panoramic and bite-wing radiographs, were taken to evaluate mandibular bone density and pulp calcification. Saliva samples were taken from both groups to determine the salivary flow rate, pH, and biochemical composition.
Results: Both groups were similar in baseline demographics. Plaque index, calculus index, and oral hygiene index of the CAPD patients were significantly worse than the controls. Percentage of decayed teeth and missing teeth of the CAPD patients had a trend towards the control. The percentage of filled teeth, decayed missing filling tooth (DMFT) index, sum of percentage DMFT, gingival index, average of spongy, and cortical bone densities, and the percentage of pulp calcification were comparable in both groups. Salivary concentrations of potassium and bicarbonate were significantly higher in the CAPD patients than in the controls. Calcium concentration was significantly lower in the CAPD patients than in the controls.
Conclusion: The CAPD patients had poorer oral hygiene than the healthy; however, DMFT, pulp calcification, and bone density were not difference from the healthy. The CAPD patients have higher salivary concentrations of potassium and bicarbonate than the healthy. In contrast, their salivary concentration of calcium is significantly lower.
Kanjanabuch P., Rujeemart T., Suwanboribarn O., Kanjanabuch T. Chulalongkorn University, Bangkok, Thailand. Objectives: The Rome III Criteria questionnaire is a reliable and reproducible tool in diagnosing constipation. To our best knowledge, none of the constipation study in peritoneal dialysis patients had utilized this questionnaire. We study the prevalence of constipation among peritoneal dialysis patients using ROME III questionnaire and examine the correlation with gram-negative peritonitis and catheter malfunction.
Methods: Peritoneal dialysis (PD) patients who attended the follow up clinic at our center from 01 December 2011 to 29 February 2012 were evaluated for chronic constipation using ROME III questionnaire. All patients were stable on PD therapy for at least 1 month and had no known intestinal abnormality or hypothyroidism. Incidence of gram-negative peritonitis and catheter dysfunction of each patient was reviewed.
Results: Forty-nine patients were evaluated. Twenty-one (42.9%) were diagnosed with chronic constipation while 28 (57.1%) were not. The chronic constipated group was younger (mean age 57.8 vs. 59.9, p=NS), predominantly male (61% vs. 46%, p=NS) and mainly on continuous ambulatory PD (CAPD) (71.4% vs. 60.7%, p=NS). The peritonitis rate for this study cohort was 1 episode per 66.5 patient-month. Gram-negative peritonitis episodes in the past 6 months was similar in both group, 2 in each group. The incidence of catheter malfunction requiring hospital visit in past 6 months was higher in the nonconstipated group (4.8% versus 7.1%, p=NS).
Conclusions: The prevalence of constipation in our study cohort using ROME III criteria, 42.9%, was higher than what was reported previously in the literature, 16%-28.9%. The chronic constipated patients in our study cohort did not experience more incidence of catheter malfunction or gramnegative peritonitis.

The Dialysis Staff Can Have the Sense of Fulfillment for Work by Making Medical Care Team
Background: The plan of privatization of the Yokosuka City Hospital was decided from the deadlock of hospital management in April 2010. Staff had lost the public worker's position, so many staffs left the hospital. In order to stop leaving staffs and maintain the motivation of the staffs, we have to change the way of medical care.
Methods: First, we made up the peritoneal dialysis team to raise up the sense of fulfillment for work. A dialysis team consists of nurse, dietitian, physiotherapist, and doctor. It is important to strengthen growth of staff and union with team members. So, we tried following challenges. First, renal study meeting had held monthly. Second, kidney disease classrooms held continuously. Third, all team staffs presented at The Japanese Society for Dialysis Therapy. Fourth, we have visited to neighboring dialysis facilities and the better system was taken in to ours. Fifth, holding of positive meeting. At this meeting, several pairs are decided. Then, a partner's good point is introduced to everybody.
Result: By doing team medical care, paramedical staffs acquires confidence, member's union becomes strong and the medical quality is improved. Our dialysis staffs desire to work together and nobody had left from our hospital. And, the patients desire to be followed in our hospital, too. The number of dialysis patients had increased by performing a team care. As a result, the dialysis therapy space in our hospital had extended twice November 2011, and the PD examination room was also extended.
Conclusion: Through these trials, our dialysis medical treatment has changed entirely.

The Effect of Newly Developed Peritoneal Dialysis Catheter on the Inflow and Outflow Time of Peritoneal Dialysis Fluid
Background: Outflow failure caused by greater omental wrapping is a serious complication for the peritoneal dialysis (PD). We developed a newly designed PD catheter (PDC, JBS-2) to reduce this complication. JBS-2 has 4 slits on catheter's side, 34 small side-holes (a diameter of 0.5 mm) in the slits and a small end-hole (a diameter of 2.0 mm). JBS-2 has been used for over 200 PD patients without this complication. Under the hypothesis that large side-holes and high outflow speed are crucial causes of omental wrapping, we examined the flow speed of PDCs.
Method: We provided six types PDCs according to the existence of slits and size/number of side-hole or end-hole. We compared flow speeds of 1.5% glucose containing PD fluid among these PDCs. Fluid weight and flow times were automatically recorded by putting bags on the electron scale connected to PC.
Result: JBS-2 took 443±5.2 seconds of inflow time and 856±44.4 seconds of outflow time. Outflow time of PDC with 0.5 mm of side-holes diameter was slightly longer than PDC with 0.7 mm. As for side-holes number (a diameter is 0.5 mm), outflow time of PDC with 64 holes was significantly shorter than PDC with 34 holes (889±13.1 vs. 909±15.0, p<0.05), but inflow times were nearly equal. PDC with 3.0 mm of end-hole diameter was significantly faster than PDC with 2.0 mm in inflow (302±3.8 vs. 464±6.5, p<0.01) and outflow (487±10.4 vs. 900±21.9, p<0.01). The existence of slits didn't affect on both flow times. All above flow times are mean ±SD (a unit is second).
Conclusion: This study suggests that side-holes may play a major role on outflow. PDC with slits, smaller side-hole size and no redundant side-holes may contribute to prevent the omental wrapping by mitigating excessive outflow speed.

Megestrol Acetate-induced Adrenal Insufficiency in a Patient on Peritoneal Dialysis
Poor appetite is a common problem in dialysis patients. Clinical trials have demonstrated the effectiveness of megestrol acetate (MA) in dialysis patients in terms of improvement in nutritional parameters, namely body weight and serum albumin. So far, reported side effects are uncommon, and mild. We here report a case of adrenal insufficiency induced by MA. A 80-year-old patient on peritoneal dialysis was put on MA 80 mg twice a day because of persistent poor appetite despite all means to optimize her health status. There was initial improvement, but 5 months after treatment, she was admitted for malaise, anorexia, hypotension, and hypoglycemia. Serum sodium level was 135 mEq/L; potassium level was 3.8 mEq/L. Serum urea nitrogen, creatinine, calcium and phosaphate levels and liver function were unremarkable. There was no evidence of infection. Her insulin requirement reduced from 60 units daily to 10 units daily. 1-microgram short synacthen test showed a low baseline cortisol level and a blunted response, with cortisol levels of 2.6 μg/dL, 10.1, μg/dL, and 13.2 μg/dL at 0, 30, and 60 minutes respectively. Adrenocorticotropin was inappropriately low, at 17 pg/mL, suggestive of secondary adrenal insufficiency. Her blood sugar and blood pressure normalized when MA was stopped, and hydrocortisone supplement was initiated. Reviewing the literature, there are case reports on MA induced adrenal insufficiency. Most of the patients have underlying malignancy. The dosage of MA used ranged from 160 mg daily to 1600 mg daily, and the duration of administration before the onset of adrenal insufficiency was between 4 weeks and 288 weeks. More importantly, studies have shown that the prevalence of asymptomatic adrenal insufficiency in patients taking MA from is between 40 and 90%. We therefore advocate a high degree of vigilance when using megestrol acetate. This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at marketing@multi-med.com S150 September 2012 -Vol. 32, SUppl. 3 PDI miscellAneous

Community-based Support for Peritoneal Dialysis (PD): an Unmet Need
Objective: Many new patients in the National Kidney Foundation Singapore (NKFS) hemodialysis program reported lack of confidence in dealing with PD therapy at home. We hypothesized that a home based support program would improve confidence. We report the implementation of such a program and a preliminary assessment of the impact on hospital PD programs and the patients.
Material and Method: All hospital-based PD programs were invited to participate. Only PD patient beneficiaries of the NKFS were recruited. The following steps were taken. 1) Program concepts and details were discussed with all participating program directors and their staff before the start of the program. 2) A roles and responsibilities coordination framework was established.
3) NKFS based PD trained nurses would then conduct home visits regularly to assess the patients' coping with PD therapy in the home environment. Focus was on technical aspects of the PD therapy, nutritional status, psychosocial well being and the early signs of medical complications of the therapy. 4) Findings would be communicated to the hospital PD programs for action.
Results: Six hospital PD programs participated. 290 patients from were visited between June-Dec 2011. Difficulties encountered were: 1) maintaining communication 2) information sharing, 3) transient confusion of the patients about the organization and responsibility of care. Complications of PD therapy detected during the home visits were exit site problems, foot ulcers, fluid overload, uncontrolled hypertension, malnutrition, and depression. All hospital PD programs reported that the program was an enhancement of their programs. Many patients reported the visits enhanced their confidence in PD therapy.
Conclusions: In our community, home based support is an unmet need in the delivery of effective PD therapy. In its implementation, coordination and collaboration between hospital and community based agencies were critical.

Patient Support by a Mobile PD Unit in Different Clinical Situations
Objectives: Many patients without medical contraindications to PD cannot be treated that way due to barriers. Assisted PD is a method to overcome these barriers and offer PD to patients.
Methods: In August 2010 a mobile PD team treating patients by automated PD (APD) overnight at home or in nursing homes was established. For full assistance a nurse visits the patient in the evening to prepare the cycler and connect the patient. At the next morning the patient is again visited and disconnected. Here we describe additional clinical situations in which we used such a mobile unit to treat and support PD patients.
Results: In total, until the end of 2011, 15 patients were treated with 1827 visits (122 per patient). The team travelled 67983 kilometers, spending 1123 hours. The average number of kilometers per visit was 37 and the average time per visit including travel was 37 minutes. APD was performed in the following situations: full assistance of dependent patients (e.g., due to immobility, blindness, Parkinson's disease) (6); partial assistance (preparation of the cycler only, patient or relative connects or disconnects, only one daily visit necessary) (1); assistance in case of intercurrent illness of patient (1); illness or holiday of other assisting person (2); incompliant patient (2); treatment of peritonitis in a patient who cannot applicate antibiotics himself (1); home training of patient or relative to perform APD (2); treatment of patients in other hospitals without dialysis ward (2).
Conclusion: A mobile unit providing professional assistance for APD can be used in many clinical situations. It helps to increase acceptance of APD by patients and their relatives. Furthermore, it reduces and shortens periods of hospitalization.

Open Dissection vs. Laparoscopic Peritoneal Dialysis Catheter Insertion: a Randomized Prospective Comparison on Outcome and Economical Evaluation
Objectives: Currently available methods for catheter placement are principally including open dissection and laparoscopic insertion. The best method is still controversial, while the laparoscopy is much expensive. In this study, we compared the perioperative complications, hospital stay and expense between the two methods.
Methods: A prospective randomized study was conducted in patients underwent PD catheter placement by either these two technique. Open dissection was performed by nephrologists under local anesthesia and laparoscopic insertion was performed by one general surgeon under general anesthesia. Peritoneal dialysis was started at the third day of the procedure.
Results: One hundred and sixty-one patients were enrolled from January to December in 2011. Eighty patients were in open dissection group and 81 patients were in laparoscopic group. The baseline was comparative between two groups. The mean hospital stay time was 14.44 days and 10.59 days in open group and laparoscopic group, respectively, which is with significant difference (p<0.05). The operative cost of open dissection and laparoscopy was CNY 400.00 and CNY 5000.00, respectively (p<0.001). But the mean hospital expense was CNY 16991.95 and CNY 14757.41 in open group and laparoscopic group respectively (p>0.05). Fluid leakage was observed in three patients in open dissection group and seven patients in laparoscopic group (p>0.05). Catheter displacement occurred in five patients in open group and in three patients in laparoscopic group (p>0.05). Eight patients in open group and ten patents in laparoscopic group had exit-site infection during the first two-week follow-up. Neither groups had peritonitis during the first two weeks after operation.
Conclusions: Compared to open dissection, laparoscopic placement does not increase the total hospital expense maybe due to the shortened hospital stay. Current study did not find which method could lower the perioperative complications and catheter displacement.
Li Z., Tang X., Fu P. Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China. Lhotta K., Knoll F., Mündle M. Department of Nephrology and Dialysis, Academic Teaching Hospital, Feldkirch, Austria.

Investigate the Esophageal Motility of Patients with Chronic Renal Failure
Objectives: Anorexia and vomiting are common in patients with chronic renal failure (CRF) and play an important role in malnutrition and mortality. We measured the characteristics of esophageal motility in CRF patients by highresolution manometry (HRM) system.
Methods: CRF patients (glomerular filtration rate <15 ml/min) with upper gastrointestinal symptoms and patients with gastroesophageal reflux disease (GERD) and normal renal function were included. Esophageal manometry was measured and the lower esophageal sphincter length (LESL), lower esophageal sphincter pressure (LESP), lower esophageal sphincter reflux rate (LESRR), type of esophageal body peristalsis and peristaltic amplitude and contraction time; upper esophageal sphincter length (UESL), upper esophageal sphincter pressure (UESP) were recorded.
Results: Twenty-one CRF patients and 23 GERD patients were enrolled. Seventeen CRF patients had esophageal body motor abnormalities (80.95%), including 8 aperistalsis, 2 completely loss of contraction, 7 alternative occurrence of peristalsis contraction and interrupted contraction, falling contraction or nonconductive contraction. Low esophageal body pressure on swallowing was found in 11 CRF patients (52.38%). Thirteen patients (61.90%) were diagnosed with motility disorders of the lower esophageal sphincter, including 3 incomplete relaxation and 3 no relaxation on swallowing. Upper esophageal sphincter incomplete relaxation occurred in 19 patients on swallowing (90.48%). There were no significant differences in LESP, LESL, UESL and duration of esophageal body peristalsis in two groups (p>0.05). UESP in CRF was significantly higher than that in GERD (p<0.05). Divided the CRF patients into reduced esophageal body peristaltic amplitude group and normal group, the reduced group had a higher age (49.18±16.04 vs. 35.40±13.2) and lower serum albumin (37.94±3.26 vs. 32.31±3.10).
Conclusion: Esophageal motility disorder in CRF patients is common. Impaired esophageal motility is associated with age and nutritional status and treatment should be strengthened in these patients. Tang X., Li Z., Fu P., Wang Y., Zhang C. Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China.
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at marketing@multi-med.com S151 pdi september 2012 -Vol. 32, sUppl. 3 ABSTRACTS OF THE 14TH CONGRESS OF THE iSpd miscellAneous

Pulse Pressure Is Not Associated with Mortality in Chinese Peritoneal Dialysis Patients
Objectives: This study aimed at estimating the predictors of pulse pressure and whether it is associated with mortality in Chinese PD patients.
Methods: All patients aged 18 years or older that commenced PD between January 1, 2000 and December 31, 2009 with PD duration longer than 6 months in Renji Hospital, Shanghai Jiao Tong University School of Medicine were included. Mean pulse pressure in the first 6 months of PD was obtained as baseline. All patients were followed up from PD initiation until death, cessation of PD, transfer to other centers, loss of follow-up or to the end of the study (December 31, 2010).
Results: A total of 498 PD patients were included (males 218, 43.8%) in the present study. After adjusting for the demographic and clinical parameters, age (B=2.34, p<0.001), serum albumin (B=0.235, p=0.004) and diabetes (B=4.93, p<0.001) were significant predictors of elevated pulse pressure. Univariate analysis showed a direct and consistent association between pulse pressure and all-cause death (HR=1.017, 95% CI 1. Conclusion: Age, serum albumin and diabetes were independent predictors of pulse pressure in PD patients. Pulse pressure is not associated with all-cause or cardiovascular death in Chinese PD patients.

Medicine Treatment in Patients on Continuous Ambulatory Peritoneal Dialysis
Objective: To evaluate the safety, tolerability, and benefits of integrated Chinese and Western Medicine treatment in patients on continuous ambulatory peritoneal dialysis (CAPD). Methods: The clinical records of all CAPD patients who have received integrated Chinese and Western Medicine treatment in our Hospital for more than 12 months were retrospectively reviewed. The clinical and laboratory parameters of the patients before and after 12 months of integrated treatment were compared.
Conclusions: Integrated Chinese and Western Medicine treatment is relatively safe and well-tolerated in CAPD patients. It may help to relieve certain symptoms that are not adequately controlled by peritoneal dialysis and conventional Western Medicine treatment and improve the nutritional status of the patients.

Introduction to and Impact of Peritoneal Dialysis Favored Policies
Objectives: Rising incidence of end-stage renal disease (ESRD) produces a commensurate increase in global economic burden of dialysis care. Peritoneal dialysis (PD) delivers similar clinical outcomes compared to in-center hemodialysis at a considerably reduced cost in most countries. Several countries and/or regions have established policies favoring PD. This study describes the background, implementation, and outcomes of these various PD favored policies.
Methods: We searched PubMed using MeSH terms for renal replacement therapy (RRT), ESRD society web sites for abstracts and PD guidelines, and country-specific government and societies/organization websites for such policies. Searches were conducted in English and also in Chinese for China, Hong Kong and Taiwan using available local internet search engines. Data were summarized by country and by policy key components and outcomes.
Results: Policies encouraging PD utilization exist in Australia, Brazil, Canada, China, Finland, Guatemala, Hong Kong, Mexico, New Zealand, Spain, and Thailand. Steps to implement PD favored policies may include: evidentiary development, economic evaluation, pilot testing, stakeholder engagement, policy/advocacy development, program evaluation and quality assurance metrics. Successful implementation of these policies increases ESRD patients' access to RRT; however, not all countries attained their goals to the same degree. For countries with PD favored policy, PD utilization rates vary considerably: Hong Kong (79.4%), Mexico (66%), Guatemala (56%), Thailand (46%), New Zealand (36%), Australia (23%), Finland (22%), Canada (18%), China (14%), Brazil (11%), and Spain (10%). PD penetration is higher in countries where public/ private partnerships support financial incentives for providers and dialysis experts are engaged as advocates for ongoing, PD-favorable, policy initiatives.
Conclusions: The number of countries and/or regions implementing PD favored policy is growing. Implementation and acceptance of these policies take time. Some countries (e.g., Hong Kong and Thailand) are successful, while others are improving. Additional strategies are required to hasten the implementation paces.

Intraperitonal Pressure (IPP) Is Not a Determining Factor for Pressure Related Complications (PRC) in Asian Adult PD Patients with Standard 2L Dwell Volume
Introduction: There are concerns that small size patients, particularly those body weight (BW) <43 kg, should use dwell volume <2 L. This study is to evaluate if standard 2-liter dwell is suitable for small size adult Asian PD patients.
Method: Over 7 years, IPP was measured during home PD training at midclavicular line in supine, and at umbilical and suprapubic levels in standing positions, 2 hours after a 2 L dwell. PD modality, any subsequent change of dwell volume was recorded. PRC (hernia, hydrothorax, retroperitoneal leakage, reflux oesophagiitis and intolerable distending abdominal discomfort) were recorded and analyzed.
Results: 120 adult (60 diabetic, 37 female) patients were studied, with mean age 58.615.6,, height 1.620.08 m. BW was <43 kg in 9 patients. The mean supine, standing umbilical and suprapubic IPP were 11.43.6, 22.86.2, 35.17.52 cm H 2 O, respectively. They correlated with each other significantly (p=0.000). IPP correlated with BW (p=0.000) but not height. 112 patients used CAPD or CCPD, and 6 used NIPD or DAPD. 20 patients used 2.5 L dwell subsequently. 28 patients (23.3%) had PRC (20 hernia, 8 leakage, 5 reflux and 1 distending discomfort, no hydrothorax). 5 of the 20 patients with hernia had hernia at more than 1 site (18 inguinal, 7 umbilical) but only 1 recurrence after herniorraphy. IPP, age, BW and height were similar between those with and without hernia or PRC. Incidence of hernia or PRC was not increased in female patients, those with BW <43 kg (p=1.00), continuous PD modalities, and those used 2.5 L dwell subsequently.
Conclusion: Hernia or pressure related complications is not uncommon in adult Asian PD patients but was not related to intraperitoneal pressure or body size when standard 2 L dwell cycle is used. The data did not support a necessity for smaller dwell volume in adult patients with BW <43 kg.

High Charlson Comorbidity Index and Hypoalbuminaemia Significantly Increase Risk of Fracture in Peritoneal Dialysis Patients
Objectives: To investigate the incidence and risk factors for fracture in peritoneal dialysis patients.
Methods: This was a case control study including peritoneal dialysis patients who developed fractures between 2006 and 2011 from a dialysis centre in Hong Kong. Details of fracture, such as site of fracture, mechanism of injury, treatment and complications were recorded. Demographic data, Charlson comorbidity index (CCI) and biochemistry were also collected. Non-fracture controls matched for age, gender and duration of dialysis, were also recruited at ratio 1:1 for fracture risk analysis.
Conclusions: Fracture is an important complication and could adversely affect outcome of dialysis patients. High CCI score and hypoalbuminemia significantly increase fracture risk.

Epidemiological, Clinical, and Laboratorial Features According to the Age of the Peritoneal Dialysis Patients
Aim: Identify any difference in demographical, clinical and laboratory features in Peritoneal Dialysis patients stratified according to ages.
Methods: A retrospective study was done on patients undergoing peritoneal dialysis from October 2010-October 2011. Etiology, modality continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD), comorbidities, hospitalizations, peritonitis episodes, the last KT/V, the last renal residual Function (RRF), the last creatinine clearance (CrCl) and the last albumin were studied.
Conclusions: No differences were observed between three groups either in hospitalization or peritonitis rate. The only difference noticed was in the modality of dialysis.

Methods in Comparison with Measured GFR (Tc99m DTPA Clearance) in Indians
Background: The aim of this study was to compare measured glomerular filtration rate (GFR) with estimates of GFR derived from various estimated creatinine clearance methods of Jelliffe, Cockcroft and Gault, and 4MDRD equations in Indian population.
Methods: We enrolled 80 patients in the study. GFR was determined by technetium-99m diethyl triamine penta-acetic acid (Tc99mDTPA) clearance. Height, body weight, and serum creatinine were measured, and GFR and creatinine clearance (CrCl) estimates calculated by various equations. Spearman's correlation was used to assess relationships between measured GFR (Tc99mDTPA clearance) and estimated clearances using the three formulae. Difference between the measured GFR and estimated clearances compared with measured GFR was examined to determine whether prediction error was independent from measurement magnitude. Analyses of differences were used to determine bias and precision. Bias was assessed by mean percentage error (MPE), calculated as the percentage difference between the estimated clearances for each formula and measured GFR. A positive bias indicates overestimation of GFR, and a negative bias indicates underestimation. Relationships were also assessed by gender and varying levels of renal function: GFR <60 ml/min, and GFR >60 ml/min.
Results: The mean measured GFR was 77.2 ml/min (range 17 to 152 ml/min). The mean bias (mean percentage error) was -4.9, -10.3, and -1.57%, respectively for the Jelliffe, Cockcroft and Gault, and 4MDRD formulas, respectively. The 4 MDRD formula overestimates the GFR in patients having GFR less than 60ml/min, where as it underestimates for GFR more than 60ml/min..
Conclusions: 4 MDRD equation seems to be most efficient in estimating GFR in Indian population.

Efficacy of Bact/Alert and BACTEC Blood Culture System in Detecting Bacterial Growth in Patients on Chronic Peritoneal Dialysis (PD) with Suspected Bacterial Peritonitis
Objective: To compare the efficacy of the BACTEC and BacT/Alert culture system in detecting bacterial growth from dialysate effluent of end-stage renal disease patients on chronic PD with suspected bacterial peritonitis.
Methods: Eighty milliliters of PD effluent were collected aseptically from chronic PD patients suspected of having bacterial peritonitis and centrifuged. Equal amount of sediments were inoculated in BACTEC and BacT/Alert blood culture systems and monitored for 5 days for microbial growth. The broth was subsequently aspirated and cultured on blood, MacConkey and chocolate agars and incubated for two days.
Conclusion: There was a trend towards earlier and higher bacterial growth with BacT/Alert blood culture system compared to the BacTec system. A larger study would be needed to confirm the findings.

Urgent Peritoneal Dialysis a Viable Solution for Acute Kidney Injury Patients
Objectives: Nowadays, PD is considered a better solution for ESRD patients to avoid CV and HD complications such as severe blood pressure decrease and hemodynamic changes with clinical impact, vascular accessrelated complications. Therefore, the aim of our study was to evaluate PD efficiency in AKI patients as a viable alternative option.
Methods: In 2011, 11 AKI patients, admitted in our Department to whom PD was hastily initiated, were included in the trial. AKI subjects in need of RRT less than 24 hours, individuals diagnosed with acute-on-chronic kidney disease and those with improved renal function based on conservative treatment were excluded from the study. The enrolled patients initiated PD after Tenckhoff catheters were successfully surgically inserted. We periodically assessed the state of anemia (complete blood count), dry body weight, malnutrition (serum albumin), kidney function (nitrogenous waste products, 24-hour diuresis, eGFR), fluid overload (bioelectrical impedance analysis) and dialysis adequacy (Kt/V). AKI severity was measured according to RIFLE criteria.
Results: We noticed that except one patient who was transferred to HD and remained on chronic dialysis, the others presented favorable outcome with completely restored renal function. 3 patients presented drug-induced AKI, 4 contrast-induced AKI, 1 diagnosed with rhabdomyolysis after intense physical effort, and 3 with unknown etiology. 2 weeks after urgent-PD started, the dialysis adequacy and a strong correlation between Kt/V values and kidney function improvement were observed (p<0.001, r=0.52).
Conclusions: According to our findings we concluded that urgent-PD might be a viable solution for individuals in need of RRT less than 72 hours. The study has some limitations and in another research, still in progress, we compare PD capacity between AKI patients and acute-on-chronic kidney disease subjects. Hopefully, our study will represent a step forward in extending PD beneficial effects to a larger number of AKI patients.

Increased Risk of Fatal Infections in Women Starting Peritoneal Dialysis
Background and objectives: Although cardiovascular disease is an important cause of morbidity and mortality in patients with ESRD, noncardiovascular causes still represent more than 50% of total deaths. We have previously shown that women starting hemodialysis have higher non-cardiovascular mortality rates compared to men. We now evaluate sex-specific outcomes in a large cohort of incident peritoneal dialysis (PD) patients.
Methods: Incident de novo PD patients entered the Andalusian Registry (SICATA, Spain) between 1999-2010, and were followed until Dec 31, 2010, or up to 5 years, for fatal outcomes. We used univariate and multivariate competing risk Cox models for all-cause and cause specific mortality in men and women, correcting for the competing event of kidney transplantation. Patients were censored if transferred to hemodialysis.
Results: A total of 1464 patients (57% men, 55.3±16.7 years) initiated PD in Andalusia. During follow-up, 350 deaths (24% of total patients), 355 renal transplants (24%) and 331 transfers to hemodialysis (23%) were recorded. Vascular disease and diabetic nephropathy was more often the cause of kidney failure in men, while other causes were more common in women. Both sexes presented identical all-cause mortality risk (crude HR, 95% CI, 0.98 [0.79-1.21]. When addressing specific causes of death, however, women showed a non-significant lower risk before transplantation of both CVD (0.76 [0.54-1.06]) and non-CVD mortality other than infections (0.88 [0.62-1.25]). On the contrary, the risk of death due to infections was 2-fold higher in women (2.05 [1. 24-3.42]) as compared to men, which held true after multivariate adjustment for age, primary renal disease, year of inclusion and initial PD modality (adjusted HR 1.81 [1.07-3.06]).
Conclusions: Women starting PD are at higher risk of mortality due to infections than men. More stringent screening measures and corrective efforts may be indicated in these women.

Appropriate for Malaysian Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients
Objectives: Malnutrition in continuous ambulatory peritoneal dialysis (CAPD) patients is associated with high morbidity and mortality. A variety of nutritional screening tools are available to identify CAPD patients at risk of malnutrition but their validity for Malaysian patients is unknown.
Methods: Nutritional assessment including medical history, anthropometric, and biochemical measurements were performed for 90 CAPD patients. Their data were used to score simplified nutritional screening tools (NRS 2000, MST, MUST) routinely used for hospital screening and their usefulness compared against tools specific for dialysis patients such as Malnutrition-Inflammation Score (MIS), Modified Subjective Global Assessment (mSGA), and the Geriatric Nutritional Risk Index (GNRI). Area under the receiver operating curve (ROC) characteristic for each tool was calculated.
Results: The mSGA tool compared to the other tools indicated the greatest degree of sensitivity to detect malnutrition (>97%) using criteria of serum albumin <40 g/L, BMI<24 kg/m 2 , cAMA <15th percentile, energy <30 kcal/kg and protein <1.2 g/kg. We found that NRS 2002 with its ROC curve closest to mSGA (AUC=0.795) was the most accurate screening tool in identifying CAPD patients at risk of malnutrition. The sensitivity, specificity, and accuracy in predicting malnutrition using NRS 2000 as per mSGA were 59%, 100%%, and 100%, respectively.
Conclusions: The NRS 2000 was the simplest and most accurate nutritional screening tool for identifying CAPD patients at nutritional risk according to the modified SGA.

Effect of Assessing and Training Peritoneal Dialysis Patients on Peritonitis Frequency
Objectives: Peritoneal dialysis (PD) is a treatment option enabling patients to lead a higher-quality life. Training is of great importance in continuous ambulatory peritoneal dialysis (CAPD). Our aim in this study was to assess PD patients' knowledge about their treatment and practice. We examined the effects of peritonitis in the PD patients' knowledge. Patients were informed about the PD after finishing the questionnaire.
Method: 29 continuous ambulatory peritoneal dialysis (CAPD) patients participated in this study. Mean age was 42.2±15.6 (15 males and 14 females). Mean PD duration was 45.6±26.1 (11-108) months. These patients had been on CAPD treatment for at least 6 months (on a 4 times per day schedule). The etiologies of primary renal disease of these participants were as follows: chronic glomerulonephritis (5), diabetic nephropathy (4), hypertensive nephropathy (6), others (14). A questionnaire was completed, and the answers were analyzed. All the demographic, laboratory information and peritonitis or exit-site infection histories of the patients were obtained from the follow-up files present in the PD unit. A form including questions about knowledge and practice' and dialysis environment was filled in for each patient. Answers were graded out of 100 points and were reported as average and percentage values.
Result: The mean 'knowledge and environment' score for all patients was calculated to be 75.9±12.5. Seventeen patients had peritonitis for once and one patient had 5 peritonitis attack in the last year. Total peritonitis incidence was found to be related to PD duration. However similar relation was not found between total peritonits frequency and PD duration. No correlation was found between total scoring and peritonitis.
Conclusion: Findings suggest that PD duration may increase peritonitis. PD patients' knowledge and training should be checked.

Hydration and Nutritional Status Assessment with Body Composition Monitoring in Peritoneal Dialysis Patients, Haemodialysis Patients, and Normal Healthy Adults
Objective: To evaluate the hydration and nutritional status of peritoneal dialysis (PD) and haemodialysis (HD) patients as compared to normal healthy adults.
Methodology: The study was conducted in consecutive PD and HD patients who had been on dialysis for ≥3 months in a single center. Patients aged <18 years old and contraindicated for Body Composition Monitoring (BCM) were excluded. Demographic data, comorbidities, dry weight, and treatment information were documented. BCM was measured in PD patients with a full abdomen, and in HD patients during the midweek pre-HD session. Overhydration was defined as OH >1.0 L. BCM was also conducted in 20 healthy adults to represent the normal population.
Conclusion: PD and HD patients are about 20 and 10 times more hydrated than normal healthy adults respectively. PD patients were also noted to be more overweight compared to HD and healthy adults. Sivathasan S., Mushahar L., Yusuf W.S., Ideris S., Omar S. Hospital Tuanku Ja'afar Seremban, Seremban, Malaysia.

Effects of Correcting Hydration Status on Blood Pressure Control and Left Ventricular Function in Peritoneal Dialysis Patients
Objective: To observe the effects of correcting hydration status on BP control and left ventricular function (LVF) in Peritoneal Dialysis (PD) patients.
Methodology: A prospective study was conducted amongst 80 consecutive PD patients who have been on PD for at least 3 months. Patients contraindicated for Body Composition Monitoring (BCM) and aged less than 18 years were excluded. Baseline demographics, comorbidities, treatment information, ultrafiltration capacity and residual renal volume were documented. Serial clinical parameters: systolic and diastolic blood pressure (SBP and DBP), blood investigations (hemoglobin, albumin, CRP), echocardiogram and BCM were done at baseline and at 4 months follow-up. Those patients who were identified as overhydrated by BCM (defined as OH >1.0 L) were subjected to intervention (dietary counseling and altering dialysis prescriptions) over a 4-month period follow-up.
Results: A total of 55 (68.8%) patients were identified to be overhydrated. Only 46 patients completed the study (5 patients died and 4 patients converted to hemodialysis). After intervention at the end of 4 months, hydration status in the cohort improved from mean OH 3.3 L to 2.5 L (p=0.001). 10 (21.7%) patients achieved OH <1.0 L. Significant improvement was noted in mean extracellular water (ECW) from 16.6 L to 15.5 L (p<0.001) and mean total body water (TBW) from 33 L to 31.5 L (p=0.044). Mean SBP and DBP reduced significantly from 156.4 to 141.1 mmHg (p=0.001) and 86.1 to 78.3 mmHg (p<0.001), respectively. The mean number of antihypertensives also decreased from 3.5 to 2.9 agents (p<0.001). Those who achieved OH <1.0 L required mean 2.7 anti-hypertensives. However, ejection fraction on echocardiogram, serum hemoglobin and albumin did not show any significant changes with correction of hydration even in those patients who achieved OH <1.0 L.
Conclusion: Correction of overhydration in PD patients reduces SBP and DBP. This directly reduces the number of antihypertensives required in those patients, but has no effect on LVF.
Sivathasan S., Mushahar .L, Yusuf W.S., Ideris S., Omar S. Hospital Tuanku Ja'afar Seremban, Seremban, Malaysia. Objectives: Malnutrition in peritoneal dialysis patients has a marked effect on prognosis and quality of life (QOL). Subjective Global Assessment (SGA) is a commonly used method for nutritional assessment. In our previous study, we developed Internet-based support systems for peritoneal dialysis patients. In the present study, we evaluated additional SGA function in our systems.
Methods: The SGA function was developed using PHP, the Apache web server, and the MySQL database. Simulated patients answered the surveys regarding physical function, gastrointestinal symptoms, and weight loss on the web page. The surveys were used as an auxiliary item of SGA on the web page. In addition, the value of weight change in the patient with SGA items was displayed in graphs and figures on the web page of the hospital from the database. For evaluation of this function, we used the Web Usability Scale (WUS), which can be evaluated according to seven evaluation items: "Impression", "Usability", "Reliability", "Operativity", "Composition", "Display" and "Responsibility". The total of 21 questions in each of 3 questionnaires and these "Average" were given scores up to 5 points. Four medical science students were evaluated using WUS.
Results: The results of the SGA were saved to the database and displayed on the web page. All seven evaluation items had scores of more than 4 points. In addition, the "Average" evaluation score of 7 items was 4.49 out of 5 points. "Operativity" had the highest score of 4.75 out of 5 points. In contrast, "Impression" had the lowest score of 4.2 out of 5 points. The task achievement quotient was 100%.
Conclusions: SGA function had a high rating in the evaluation. SGA can be evaluated easily using this function. Further studies in actual peritoneal dialysis patients are required.

A Comparison of Clinical Outcomes between Assisted and Self-care Peritoneal Dialysis: a Single Center Experience
Objectives: Chronic ambulatory peritoneal dialysis (CAPD) is often considered to be best suited to patients who are physically independent. For patients who cannot fulfill these criteria, peritoneal dialysis (PD) is often still performed with the aid of a trained assistant. However, there remains limited data regarding the clinical outcomes of patients undergoing this modality. The objective of the present study is to observe the outcome of assisted PD compared to traditional self-care PD.
Methods: All CAPD patients under regular follow up in the University of Malaya Medical Centre were recruited. Patients were divided into 2 groups, assisted PD (aPD) and self-care PD. Data was obtained by review of patients' medical charts. Statistical analysis was performed using SPSS version 16.0.
Results: A total of 71 patients were recruited with 39 in the self-care group and 32 in the aPD group. Patients undergoing aPD were significantly older (65.56 years vs. 48.36 years, p=0.00) but were otherwise similar to the self-care group. The main causes for requiring assistance were physical disability (84%, n=27) and cognitive impairment (13%, n=4). aPD patients had significantly lower creatinine, higher hemoglobin, lower phosphate and iPTH levels. There were no differences seen in peritonitis rates between the 2 groups, but patients in the self-care group were more likely to require hospitalization (frequency=0.09 vs. 0.51, p=0.00) and when hospitalized, had significantly longer hospital stays (6.5 vs. 2.67 days, p=0.03).
Conclusions: Clinical outcomes among patients in the assisted group were similar or even better than the self-care group suggesting that assisted PD can be a safe option for patients who may not be good candidates for self-care PD.

A Comparison between Domestic Helper-and Family Memberassisted Peritoneal Dialysis
Objectives: Assisted peritoneal dialysis (aPD) with a trained assistant has been touted as an alternative for patients who are unable to care for themselves. In our program, this role has traditionally been relegated to a family member. However, many families may not have the resources necessary to carry out this role. The objective of this study is to compare clinical outcomes between family member assisted and domestic helper assisted PD.
Methods: All assisted PD patients under regular follow up in the University of Malaya Medical Centre were recruited. Patients were divided into 2 groups, family member-assisted (FM) and domestic helper-assisted (DH). Data was obtained by review of patients medical charts. Statistical analysis was performed using SPSS version 19.0.
Results: A total of 32 patients were recruited. 26 received assistance from a family member (FM) while 6 were aided by a domestic helper (DH). Baseline demographics were similar between both groups. Mean age in the FM group was 65.35±12.5yrs and 66.5±7.28yrs in the DH group. Duration of PD ranged between 23.46±23.77 (FM) and 15.58±14.94 (DH) months. Diabetes was the primary cause of renal failure in both groups (69.2% FM group, 83.3% DH group) followed by hypertension (26.9% FM group, 16.7% DH group). Besides a trend towards higher CRP levels in the DH group (p=0.58), other biochemical parameters were similar. Clinical outcome measures for hospitalization and PD related infections were also not statistically significant between groups.
Conclusions: Assisted PD patients cared for by domestic helpers had clinical outcomes no different from those cared for by family members. This suggests that domestic helpers can reliably be trained to perform assisted PD.

Peritoneal Dialysis in Acute Renal Failure
Objectives: Hemodialysis has become the preferred option for renal replacement therapy among patients with acute renal failure. However, peritoneal dialysis may still have a role to play as it requires less expertise to operate and generally can be provided at a lower cost. It may also be a better option for patients with hemodynamic instability and may promote a higher degree of renal recovery. We seek to observe the outcome of patients with acute renal failure managed with peritoneal dialysis in our centre.
Methods: This was a retrospective cohort study of all patients requiring peritoneal dialysis for acute renal failure in the University of Malaya Medical Centre over a 3-year period from 2007-2009. Data was abstracted from medical records. Baseline demographic data were collected. Outcomes of interest included cause of acute renal failure, complications related to peritoneal dialysis, survival and recovery of renal function at 30 days. Data were tabulated and analyzed using SPSS version 19.0.
Conclusions: Peritoneal dialysis appears to be a safe and viable alternative for patients with acute renal failure. However, mortality among patients with acute renal failure remains high. Recovery of renal function was high among patients who survived. More research needs to be done on measures to improve mortality in this cohort.
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miscellAneous A Retrospective Analysis of Patient Outcomes on Peritoneal Dialysis: Technique and Patient survival and the Impact of Switching to Hemodialysis
Objectives: PD remains an integral form of renal replacement therapy and has witnessed changes in the last decade including increase in automated PD, assisted PD, use of icodextrin and biocompatible solutions. To establish the impact of prevailing PD practice at our center we carried out a retrospective outcome analysis.
Methods: Medical records of all patients commencing PD over a 7-year period between 2004 and 2010 to the end of the observation period in March 2011 were reviewed. Data collected included demographic, clinical, PET and adequacy. Outcome was analyzed in terms of patient and technique survival using Cox's proportional hazards model.
Results: 286 patients commenced PD in the 7-year period. Mean age was 55.2 y (SD 17.6), 39% were female and median follow-up was 24 months (Range 0.8-84). 76 patients (27%) were transplanted and 102 (36%) died in the observation period. Patient survival probabilities at 3 and 5 years were 0.69 and 0.53, technique survival 0.67 and 0.58, transplantation 0.23 and 0.32, respectively. Peritonitis was the main cause for technique failure (42%), while ultrafiltration failure 6.3%. High Davies comorbidity grade, creatinine and BMI were independent predictors of technique failure. Sudden cardiovascular events were the predominant mode of death (31%), followed by debilitation (19%), and peritonitis (13%). PD failure was an independent predictor of death. When successful switch to HD was analyzed, hemodialysis via catheter presented an elevated death hazard compared to staying on PD or HD through fistula.
Conclusions: Technique and patient survival of our cohort is comparable to published reports. However, the incidence of ultrafiltration failure and predictive value of residual renal function in technique survival are less so. Cardiovascular mortality and morbidity from peritonitis are predominant adverse events despite achieving recommended peritonitis targets. Nature of vascular access has serious impact on outcome when switching from PD to HD.

Prevalence of Travelling among Peritoneal Dialysis Patients in a Tertiary Healthcare Hospital in Malaysia
Introduction: The increasing availability and number of patients on peritoneal dialysis in Malaysia has opened more opportunities for travel.
Objective: The primary objective was to determine the prevalence of travelling among our peritoneal dialysis patients and factors associated with travel. Secondary objective was to determine any association between travelling and peritonitis.
Methods: A prospective study involving all patients on peritoneal dialysis for at least 3 months in our unit as of 1st January 2012 was conducted. Patients who were deemed unfit for travel we excluded from the study. History of travel was obtained during follow up or via phone interview.
Results: 98 peritoneal dialysis patients were identified. 88 patients were analyzed and 10 were excluded. Mean age of all our peritoneal dialysis patients were 57.8 years. 40.9% (36 patients) had reported travelling, while on peritoneal dialysis. Among patients who travelled, 27 were on CAPD while 9 were on APD. Patients who travelled were younger (51.44 vs. 62.25 years, p<0.001) and those who were on peritoneal dialysis longer were more likely to travel (3.22 vs. 1.96 years, p=0.013). 94.4% had travelled to a domestic destination, while 25% had travelled internationally. Travelling was not associated with increased rates of peritonitis.
Conclusion: The high number of patients on peritoneal dialysis in our unit is very encouraging. Younger age and longer duration on peritoneal dialysis were factors associated with travel.

The Endothelial Glycocalyx in Uremia, Relationships with Inflammation, and Oxidative Stress
Introduction: Little is known about the endothelial glycocalyx and the relationship with inflammation and oxidative stress in uremia. Our objective was to investigate the relationship between inflammation as measured by CRP and IL-6, a marker of oxidative stress (MDA, malonilaldehyde) and the status of the glycocalyx as measured by an imaging method and determinations of glycocalyx constituents in blood.
Methods: Investigations were carried out in 40 dialysis patients and 21 age and sex-matched healthy controls. We performed Sidestream darkfield imaging of the sublingual blood vessels. The status of the endothelial glycocalyx in individual blood vessels was assessed by measuring the dynamic of red blood cells column width near the vessel wall. MDA was measured by HPLC, Hyaluronan, Hyaluronidase activity, Syndecan-1 and IL-6, were measured with commercially available ELISAs.
Conclusion: Dialysis patients appear to have shedding of glycocalyx constituents into blood, and a deeper penetration of erytrocytes into glycocalyx consistent with loss of glycocalyx barrier properties. Increased levels of MDA and IL-6 seem to lead to an increased binding of hyaluronidase to its substrates and consumption of the enzyme.

Corticosteroids Treatment Improves Mortality and Clinical Outcome in Patients at Risk of Encapsulating Peritoneal Sclerosis (EPS) who Presented with Nonresolving Peritonitis Following Tenckhoff Catheter Removal for Refractory Bacterial Peritonitis
Objectives: Early diagnosis of EPS is crucial to direct early treatment to improve outcome. Patients who have Tenckhoff (TK) catheter removed for refractory peritonitis are at high risk for evolving to EPS. Our aim was to assess whether such patients with nonresolving peritonitis were at an increased risk of developing EPS, and the effect of corticosteroids or tamoxifen on the disease progression.
Methods: Retrospective comparison of the clinical characteristics and outcome of patients presented with non-resolving peritonitis (persistent peritoneal inflammation for ≥3 weeks, but negative sepsis workup, ("high-risk" group, n=39) with those who had rapid resolution of peritonitis ("control" group, n=23) following TK catheter removal for refractory bacterial peritonitis between January 2005 and December 2010. Prednisolone (in 56%, 0.5 mg/kd/d for 4 wks, then tailed off) and tamoxifen were introduced since 2008 for treatment of these "high-risk" patients and the effect was evaluated.
Results: The "high-risk" group had been on a significantly longer duration of peritoneal dialysis (72±43 vs. 42±30 months, p=0.003) and a higher D/P Creatinine ratio (0.768±0.141 vs. 0.616±0.091, p=0.004) when compared with the controls. Eleven patients in the "high-risk" group developed significant abdominal symptoms with intestinal obstruction (31% vs. 0%, p=0.002), and the mean survival time from the index peritonitis episode was significantly shorter than the controls (165±37 vs. 178±9 days, p=0.035). Corticosteroids treatment was associated with a lower six-month mortality (18% vs. 59%, p=0.01) and a lower incidence of full-blown EPS (5% vs. 47%, p=0.005). There were no major side-effects noted. No independent effect of tamoxifen was found.
Conclusions: Patients with persistent peritoneal inflammation despite adequate antibiotic therapy following TK removal for CAPD peritonitis were at an increased risk of EPS progression, and corticosteroids treatment might retard such progression and improve the outcomes.