Catherine Michel

The influence of automated peritoneal dialysis on the decrease in residual renal function.

BACKGROUND Automated peritoneal dialysis (APD) has been increasingly used in recent years. Our purpose was to investigate whether the good preservation of residual renal function (RRF) that has been reported in patients on continuous ambulatory peritoneal dialysis (CAPD) is also observed in APD. METHODS RRF was determined and compared prospectively over 1 year in two groups of peritoneal dialysis (PD) patients: 18 consecutive new patients starting on APD (12 continuous cyclic peritoneal dialysis (CCPD) patients and six nightly intermittent peritoneal dialysis (NIPD) patients) and 18 selected patients who had started on CAPD at the same time and were matched for baseline characteristics. RRF was assessed on normalized creatinine clearance (ml/min/1.73 m2) measured before the start of PD, at 6 months, and at 1 year. Wilcoxons rank sum test was used to compare differences between the two groups. RESULTS Creatinine clearance (ClCr) was 6.1 ml/min in the APD group and 6 ml/min in the CAPD group at the start of PD. The monthly rate of ClCr decrease was significantly higher in the APD group: -0.28 ml/min vs -0.1 ml/min (P = 0.04) at 6 months and -0.26 ml/min vs -0.13 ml/min (P = 0.005) at 1 year. RRF decreased at the same rate in patients treated with NIPD or CCPD. The daily instilled volume of 3.86% glucose dialysis solution (l/day) was higher in APD patients than in CAPD patients: 2.5 vs 0 at 6 months and 1 year but there was no significant difference in ultrafiltration rate (l/day) between APD and CAPD patients at these timepoints: 0.53 vs 0.6 and 0.88 vs 0.7 respectively. There was no difference between the two groups in body weight and blood pressure, which remained stable in both groups throughout the study period. CONCLUSIONS RRF declined rapidly in APD patients whereas it was well preserved in CAPD patients. This may be explained by the less stable fluid and osmotic load together with the intermittent nature of APD and the larger use of hypertonic dialysate. RRF should be closely monitored in APD patients in order to adjust PD prescriptions and maintain adequacy.

Fungal Peritonitis in Patients on Peritoneal Dialysis

Fungal peritonitis (FP) is a serious complication of peritoneal dialysis, both in terms of morbidity and mortality. Available data on the effectiveness of fluconazole in eradicating FP without catheter removal are still controversial. We reviewed 20 FP cases that occurred among 325 patients who underwent peritoneal dialysis in our center between January 1984 and January 1992, in order to establish whether a profile of patients at risk of developing FP could be identified and to evaluate the effectiveness of fluconazole in treating FP (7 cases). Age, sex, a particular cause of end-stage renal disease, and the presence of diabetes did not correlate significantly with the development of FP. The risk of FP increased in patients on immunosuppressive treatment. Sixteen of our 20 patients had bacterial peritonitis during the month before they developed FP. Nineteen were treated with antibiotics. Neither the type of bacterial organism isolated during the bacterial peritonitis preceding FP nor modality and duration of antibiotic treatment correlated significantly with the development of FP. Patients who subsequently developed FP were more frequently treated with antibiotics while in hospital (p < 0.001). Candida species accounted for 15 of our 20 FP cases (75%), with Candida albicans being by far the most common isolate. Treatment strategies varied among the 20 patients. The combination of intravenous or intraperitoneal administration of 5-fluorocytosine and oral administration of fluconazole was used in 7 cases: only 1 patient was cured without catheter removal, 1 patient died within the first 4 days of treatment, removal of peritoneal catheter was necessary in the other 5 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

AA amyloidosis in systemic lupus erythematosus: an unusual complication

a nephrotic syndrome. The only SLE activity she Introduction reported during this time were brief episodes of polyarthralgia. Laboratory tests showed a normal creatinAA amyloidosis is a complication of chronic inflamine level, albumin concentration at 1.79 g/dl, heavy matory diseases including Crohn’s disease, rheumatoid proteinuria (3 g/day), no haematuria, antinuclear antiarthritis, ankylosing spondylitis, and juvenile rheumatbody titres of 1/500, no anti-DNA antibodies, no oid arthritis. In contrast to the past, today it is less monoclonal gammopathy, and normal levels of comfrequently associated with chronic infectious diseases plement factors. The CRP level was high (6.7 mg/dl ) such as tuberculosis. AA amyloidosis has also been despite the presence of a nephrotic syndrome. No reported in cancer, Muckle–Wells disease and familial infectious disease was found. Although there were no Mediteranean fever (FMT) where the incidence differs signs of active SLE, a diagnosis of membranous between less than 10% for Armeniens and Arabs and glomerulopathy was entertained and renal biopsy was over 30% among Turks and Sephardic Jews. performed which revealed massive glomerular and Conversely, AA amyloidosis is not a classic comvascular Congo-red-positive areas exhibiting green plication of SLE, and fewer than 20 cases have been birefringence under polarized light, staining with reported in English worldwide, although cases of SLE anti-AA antibodies but not with other sera (Figure 1). with monoclonal gammopathy may be complicated by Optic microscopy and immunofluorescence study AL amyloidosis. detected no SLE nephritis. Electron-microscopic We observed one unusual patient with SLE analysis was not performed. complicated by AA amyloidosis. The patient received colchicine (1 mg/day). Subsequently, clinical and biological findings suggested hepatic and intestinal amyloid involvement. Renal Case insufficiency began 2 months later and progressed in 6 months to end-stage renal disease; the patient was then A 55-year-old woman with a 4-year history of SLE without renal involvement was admitted with a nephrotic syndrome. SLE had been diagnosed when she was 51 years old, following a 10-year history of isolated dermatological problems: she presented with non-destructive and non-deforming polyarthritis, skin rash, and iliac thrombophlebitis. Laboratory investigation revealed high titres of antinuclear (1/1000) and anti-DNA (82 U/ml ) antibodies. There was no haematuria, no proteinuria, the creatinine level was normal, and the C-reactive protein level (CRP) was very high (3.6 mg/dl ); lupus anticoagulant and IgG anticardiolipid (34 U GPL) were also present. She met four of the American Rheumatism Association’s criteria for SLE, and was treated with oral corticosteroid. She was readmitted to our service 4 years later with

Effects of Intravenous Polymaltose Iron on Oxidant Stress and Non-Transferrin-Bound Iron in Hemodialysis Patients

Background: The use of intravenous iron to correct anemia in end-stage renal diseases (ESRD) has been suspected of catalyzing the production of activated oxygen species and promoting oxidative damage. We investigated the pro-oxidative potential of injected iron in hemodialysis patients. Methods: In study A, 65 patients with ESRD were studied. 20 patients received weekly infusions of iron polymaltose (maltofer), whereas 45 patients had been off iron therapy for more than 2 months. In study B, 12 patients were investigated during two consecutive hemodialysis sessions, one session without and one session with infusion of 100 mg of maltofer over 4 h. Serum iron status, non-transferrin-bound iron (NTBI) and markers of oxidative stress were studied in blood samples from these patients. Results: In study A, NTBI was detected in 41% of the patients and the proportion of NTBI-positive patients was the same whether or not they received iron therapy. In study B, the serum iron and transferrin saturation index increased during iron infusion and NTBI transiently appeared in some patients but markers of oxidative stress were not significantly affected. Conclusion: Although ESRD patients have a high prevalence of NTBI in their serum, no correlation could be established between the presence of NTBI and an increased oxidative stress. The slow infusion of maltofer does not promote a significant increase in the plasma concentration of oxidative stress markers. It may therefore be considered as a safe complement to erythropoietin therapy.

Icodextrin does not impact infectious and culture-negative peritonitis rates in peritoneal dialysis patients: a 2-year multicentre, comparative, prospective cohort study.

Background. Icodextrin is a glucose polymer derived by hydrolysis of cornstarch. The different biocompatibility profile of icodextrin-containing peritoneal dialysis (PD) solutions may have a positive influence on peritoneal host defence. Furthermore, cases of sterile peritonitis potentially associated with icodextrin have been reported. Methods. The primary objective of this multicentre, longitudinal, observational, non-interventional, prospective cohort study, which included 722 PD patients, was to evaluate the incidence of overall peritonitis in patients treated with icodextrin-containing PD solutions (Extraneal™) used during one long-dwell exchange/day compared with those treated with non-icodextrin-containing PD solutions. The secondary objective was to determine if culture-negative peritonitis rates differed between patients treated with icodextrin from two independent manufacturers. All peritonitis episodes were assessed by a Steering Committee in a blind manner. Results. There was no significant difference between icodextrin-treated and control patients in the adjusted overall, culture-positive or culture-negative peritonitis rates. When stratified by the icodextrin supplier, there was no significant difference in the adjusted rate of culture-negative peritonitis episodes between groups. Conclusion. Subjects receiving icodextrin as part of their PD regimen experienced neither a higher rate of culture-negative peritonitis nor a lower rate of infectious peritonitis compared with non-icodextrin users. There was no significant influence of the icodextrin raw material supplier on peritonitis rates.

Effect of Recombinant Human Erythropoietin on Nutritional Status and Plasma Lipids in Uremic Patients

Dr. Béatrice Viron, Service de Néphrologie, Hôpital Tenon, 4, rue de la Chine, F-75020 Paris (France) Dear Sir, Improved appetit and food intake have been reported from earlier studies of patients treated with recombinant human erythro-poietin (r-Hu EPO) [1]. An increase in BUN, plasma creatinine and plasma phosphorus values as well as, in some cases, severe hyper-kaliemia were observed in certain series [2]. Contrasting with their generally poor nutritional status [3], plasma lipid abnormalities are common in uremic patients [4], especially those maintained on hemodialysis (HD) or peritoneal dialysis (PD). In those patients, particularly prone to diffuse atherosclerosis [5], any deleterious effect of r-Hu EPO on plasma lipids might question the benefit of correcting anemia with this treatment. However, the effect on plasma lipids of the r-Hu-EPO-induced changes concerning the nutritional behavior of uremic patients had not been assessed yet. We have studied 12 patients, 7 HD (4 males, 3 females, mean age 57) and 5 PD (3 males, 2 females, mean age 70). Plasma lipids were measured together with different reliable parameters of the nutritional status [3], first, before initiating r-Hu EPO, then 6 months from the date of correction of anemia (defined as Hb > 10 g/dl). The following data were collected: body mass index, triceps skin-fold thickness (TST), arm muscle circumference (AMC), serum albumin, prealbumin, transferrin, total cholesterol, triglycerides (Tg), apolipoprotein (Apo) Al, Apo B, retinol-binding protein and acid αΓglycopro-tein. These values were compared to those obtained from 7 HD and 12 PD nonanemic patients, matched for age, sex and duration of maintenance dialysis. Before EPO, Hb was 7.2 ± 0.4 g/dl in the HD and 8.6 ± 0.7 g/dl in the PD patients. The PD patients had decreased serum albumin (2.9 ± 0.4 g/dl), increased Tg (2.3 ± 1.4 mmol/ 1) and Apo B (0.16 ± 0.05 g/dl), whereas only Tg were abnormally high (2.0 ± 1.1 mmol/l) in HD patients. However, anthropometric hallmarks of malnutrition were exclusively found in male HD patients, who had low values of body mass index (20.9 ± 1.0 kg/m2), TST (4.2 ± 1.1 mm) and AMC (22.4 ± 2.7 cm). After 6 months with stable Hb (HD: 10.4 ± 0.8 g/dl; PD: 10.1 ± 0.6 g/dl), only the male HD patients exhibited a significant increase in TST (5.1 ± 1.2 mm; p < O.Ol) and AMC (23.1 ±

Erosive spondyloarthropathy in peritoneal dialysis patients

Erosive spondyloarthropathy (ESA) is common in long-term hemodialysed patients. However, it has been little recognized in peritoneal dialysis (PD) patients. In a retrospective study, we found severe ESA in 7 of the 87 (8%) patients undergoing PD in our center. Characteristics of our population were advanced age and short duration of dialysis (27±20 months). ESA patients were older than non ESA (74±4 vs 68±11 yrs,p<0.01). Secondary hyperparathyroidism and dialysis amyloid arthropathy were also possible pathogenic factors. Patients were followed for 4 years or until death and remained stable in most ESA cases. We conclude that ESA is age-related, is as frequent in PD as in HD populations and is not related to one single underlying mechanism.