Alex Wai-Yin Yu

Independent effects of residual renal function and dialysis adequacy on nutritional status and patient outcome in continuous ambulatory peritoneal dialysis

Dialysis adequacy has a major impact on outcome of continuous ambulatory peritoneal dialysis (CAPD) patients. However, there is a substantial confounding effect by residual renal function in most studies. We differentiated the effects of dialysis adequacy from those of residual renal function on nutritional status and outcome of CAPD patients. We identified 168 CAPD patients treated in our center between September 1995 and December 1996 and categorized them into three groups: 49 patients with an average total Kt/V of 1.93 +/- 0.18 and a median residual glomerular filtration rate (GFR) of 0. 07 mL/min/1.73 m(2) in the dialysis-dependent (DD) group; 48 patients with an average total Kt/V of 2.03 +/- 0.25 and a residual GFR of 2. 33 mL/min/1.73 m(2) in the residual renal function (RRF) group; and 71 patients with an average total Kt/V of 1.38 +/- 0.22 and a residual GFR of 0.05 mL/min/1.73 m(2) in the control (CTL) group. They were followed-up for 1 year to compare baseline nutritional status and 1-year morbidity. Baseline normalized protein catabolic rates (NPCR) are 1.00 +/- 0.20 and 0.96 +/- 0.19 (for RRF and DD, respectively) versus 0.89 +/- 0.16 g/kg/d for CTL (P < 0.01). Percentage lean body mass (%LBM) was 71.6 +/- 9.8 and 71.5 +/- 10.0 (for RRF and DD, respectively) versus 65.2 +/- 8.5% for CTL (P < 0. 001). No difference was seen in the nutritional status between RRF and DD groups. Duration of hospitalization for 1 year was 6.9 +/- 11. 8 days in the RRF group versus 14.9 +/- 25.1 in the DD and 10.6 +/- 11.6 days in the CTL groups (P < 0.05). The peritonitis rate was 44. 4 patient-months for the RRF group, versus 13.6 for the DD and 12.9 for the CTL groups (P < 0.05). There also was a trend toward superior 1-year technique survival in the RRF group, but the number of observations was small. There was no difference in duration of hospitalization, peritonitis rate, and technique survival between the DD and CTL groups. Short-term morbidity in patients without residual renal function appears to be independent of total Kt/V, although Kt/V may have some effects on nutritional status. The assumption that renal and peritoneal clearances are equivalent must be carefully reexamined. Further studies on the effect of dialysis adequacy in patients without residual renal function are urgently needed.

DIALYSIS ADEQUACY OF ASIAN PATIENTS RECEIVING SMALL VOLUME CONTINUOUS AMBULATORY PERITONEAL DIALYSIS

The usage of three × 2 liter daily exchanges is adopted as the standard CAPD regime in Hong Kong over the last 10 years due to budgetary constraint. This dialysis prescription is considered suboptimal in Western standard. However, the necessity of maintaining Kt/V > 1.7 for CAPD dialysis adequacy is not unanimously agreed. We performed a cross-sectional study of 117 patients on CAPD. Seventy-eight percent of our patients had 3 × 2 liter daily exchange while the rest had 4 daily exchanges. Fifteen percent of patients were diabetic. Patients with Kt/V < 1.7 were similar to those with Kt/V > 1.7 in age, duration of CAPD, BUN, plasma creatinine, albumin, peritonitis rate, and incidence of hypertension. Patients with Kt/V ≥ 1.7 had higher hemoglobin, higher nPCR, more residual renal function; and more of them received 4 daily exchanges. Their peritoneal permeability did not differ. Their employment and rehabilitation status was also similar. Our 5-year survival was 79% despite a lower Kt/V. Notably, the protein catabolic rate of our patients was higher than that in Western patients. This is likely due to dietary difference. Our study suggests small-volume dialysis may be acceptable in Asian population with smaller body size given the financial constraint.

Xanthomonas maltophilia peritonitis in uremic patients receiving continuous ambulatory peritoneal dialysis

Xanthomonas maltophilia peritonitis has been only occasionally reported in patients receiving continuous ambulatory peritoneal dialysis. We present a series of six cases of peritonitis caused by such bacteria, accounting for 1.5% of all peritonitis episodes encountered in our renal unit over the past 5 years. Recent bacterial peritonitis treated with broad-spectrum antibiotics was the major risk factor, and the outcome was poor with medical treatment alone. Secondary peritonitis, especially fungal, was common and probably related to the prolonged course of antibiotics. All patients eventually required removal of the catheter, either because the effluent failed to clear up or because of secondary peritonitis. We suggest that X maltophilia peritonitis be treated with double antibiotics as soon as it is diagnosed. To prevent the development of superimposed infection after prolonged administration of antibiotics, the Tenckhoff catheter should be removed if the peritonitis fails to respond to a short course of antibiotics.

Posttransplant Epstein-Barr virus-associated myogenic tumors involving bone: A case report

Epstein–Barr virus (EBV)–associated myogenic tumors in immunocompromised patients were recently recognized, but their biologic behavior remains only partially understood. Although observations so far have permitted the recognition of similarities between posttransplant myogenic tumors and posttransplant lymphoproliferative disorders (PTLD), the number of reports are still few, and new experiences continue to be informative.

Use of low-dose low molecular weight heparin in hemodialysis☆

We investigated the lowest effective dosage of low molecular weight (LMW) heparin for hemodialysis in comparison to unfractionated (UF) heparin. Initial hemodialysis sessions were undertaken in 10 uremic patients with UF heparin of the dose habitually required for each patient. Four-hour hemodialysis sessions were then undertaken with LMW heparin (nadroparin) in a single bolus (200 anti-Xa unit Institut Choay/kg [aXaU IC/kg], 175 aXaU IC/kg, 150 aXaU IC/kg, or 125 aXaU IC/kg; two sessions for each dosage). Anti-Xa levels and activated partial thromboplastin time (APTT) were monitored hourly during dialysis. Fiber bundle volume of dialyzer was measured before and after dialysis. Urea clearance was determined at the onset and completion of dialysis. There were no episodes of excessive bleeding, clotting of dialyzers, or clots in air traps with UF heparin or LMW heparin. A 35% increase in APTT above baseline was observed in all dialysis sessions 1 hour after LMW heparin bolus, but the APTT decreased rapidly thereafter. The anti-Xa levels exceeded 0.5 U/mL for all sessions using LMW heparin irrespective of the dosage. No significant reduction of urea clearance was found in dialysis with either UF or LMW heparin. No reduction of fiber bundle volume of dialyzer was observed in dialysis with either UF or LMW heparin, although a small reduction (3%) was observed in dialysis with LMW heparin at 125 aXaU IC/kg. We concluded that the use of LMW heparin for hemodialysis is safe and effective as compared with UF heparin. The lowest effective dosage can be reduced to 125 aXaU IC/kg in high-risk patients to reduce hemorrhagic complications.

Increasing plasma phosphorus values by enriching with phosphorus the "acid concentrate" of a bicarbonate-buffered dialysate delivery system.

Each of seven hypophosphatemic hemodialysis patients was dialyzed with a phosphorus-enriched, bicarbonate-buffered dialysate. The latter was prepared by the introduction of sodium phosphate salts to the “acid concentrate” of a bicarbonate-buffered dialysate delivery system. The patients tolerated the procedure well and their hypophosphatemia improved.

Pain perception following subcutaneous injections of citrate-buffered and phosphate-buffered epoetin alpha.

Subcutaneous injection of citrate-buffered epoetin alpha (EPO-α) causes pain. Substitution of citrate buffer with a phosphate buffer in the EPO-α resulted in a significant reduction in duration and severity of pain. It is possible that sodium citrate which is present in the EPO-α may be the agent that causes discomfort in the patients.

Increasing home based dialysis therapies to tackle dialysis burden around the world: a position statement on dialysis economics from the 2nd Congress of the International Society for Hemodialysis

PHILIP KAM-TAO LI, WAI LUN CHEUNG, SING LEUNG LUI, CHRISTOPHER BLAGG, ALAN CASS, LAI SEONG HOOI, HO YUNG LEE, FRANCESCO LOCATELLI, TAO WANG, CHIH-WEI YANG, BERNARD CANAUD, YUK LUN CHENG, HUI LIN CHOONG, ANGEL L DE FRANCISCO, VICTOR GURA, KAZO KAIZU, PETER G KERR, UN I KUOK, CHI BON LEUNG, WAI-KEI LO, MADHUKAR MISRA, CHEUK CHUN SZETO, KWOK LUNG TONG, KRIANG TUNGSANGA, ROBERT WALKER, ANDREW KUI-MAN WONG, ALEX WAI-YIN YU, on behalf of the participants of THE ROUNDTABLE DISCUSSION ON DIALYSIS ECONOMICS in the SECOND CONGRESS OF THE INTERNATIONAL SOCIETY FOR HEMODIALYSIS (ISHD 2009)*

Phosphorus-Enriched Hemodialysates: Formulations and Clinical Use

Although hyperphosphatemia is a cardinal feature of renal failure, the occasional patient suffering from end‐stage renal disease (ESRD) may present with hypophosphatemia. For example, hypophosphatemia can develop in ESRD patients if they suffer from malnutrition or if they are aggressively dialyzed. Hypophosphatemia is commonly prevented or treated with the oral or the intravenous administration of soluble phosphate salts; however, determination of the required oral or intravenous dose is difficult. Under appropriate circumstances, phosphorus‐enriched dialysates can also be employed for the purpose of phosphorus administration. Various preparations of soluble phosphate salts can be used to enrich hemodialysates.

Association of IgA nephropathy with T-cell receptor constant alpha chain gene polymorphism

T-cell receptor (TCR) proteins recognize a complex of an antigen-derived peptide bound to the cell surface products of the major histocompatibility complex (MHC) that could be of importance in the immunopathogenesis of IgA nephropathy (IgAN). Previous studies found no difference on TCR constant beta chain gene frequencies in IgAN compared with control. Yet no study on the TCR alpha gene in IgAN was reported. We studied the TCR C alpha gene polymorphisms by restriction fragment length polymorphism (RFLP) in 53 patients with IgAN and in comparison with 67 healthy controls. The patients were also classified into different histopathological grading (I, II, and III with increasing histological severity) and renal functions. The extracted DNA were digested with Taq I enzymes and probed with a full-length TCR-alpha cDNA clone p1.2alpha probe. A 7-kb C-alpha Taq 1 fragment is found in 32 of 53 patients (60.3%) compared with 26 of 67 controls (38.8%) (P < 0.05). There was no association of any polymorphic fragment, including the 7-kb fragment, with either the histological grading or renal function. It is concluded that the TCR C-alpha gene is associated with IgAN but not with the prognosis of the disease.