Yoshitaka Ishibashi

Peritoneal Morphology After Long-Term Peritoneal Dialysis with Biocompatible Fluid: Recent Clinical Practice in Japan

♦ Background: Morphology changes of the peritoneal membrane after long-term peritoneal dialysis (PD) consist of denudation of peritoneal mesothelial cells, interstitial sclerosis, and hyalinizing vasculopathy. Those changes are considered to be the result of uremia and bioincompatible effects of conventional acidic lactate-buffered dialysate with glucose degradation products (GDPs). In the last decade, biocompatible dialysate with neutral pH and low GDPs has become widely used. Clinical practice has been modified in Japan, especially for anuric patients, and now includes the use of hybrid therapy. The impact on peritoneal morphology has not been well reported. ♦ Objective: The aim of the present study was to investigate the long-term effect on peritoneal morphology and function of biocompatible fluid use and current clinical practice in Japan, including hybrid dialysis therapy. ♦ Methods: We evaluated peritoneal biopsy specimens from patients who had undergone PD for more than 3 years. We used the average peritoneal thickness (APT) of the submesothelial compact zone as a marker of interstitial sclerosis and the lumen/vessel diameter ratio (L/V ratio) at postcapillary venules as a marker of hyalinizing vasculopathy. Demography and other data for the patients, including dialysate-to-plasma (D/P) ratio of creatinine, were obtained at baseline and every 6 months by peritoneal equilibration test. ♦ Results: Between 2002 and 2009, 110 patients started PD therapy with biocompatible dialysate at Tokyo University Hospital. Among them, 11 patients (8 men, 3 women; age: 54.2 ± 11.8 years; 1 with diabetes mellitus) were enrolled into this morphology study. The mean duration of PD in this group was 61 ± 11.3 months, and the mean time to peritoneal biopsy was 58 ± 15.1 months. The median APT was 180 μm (96 – 1424 μm), and the median L/V ratio was 0.66 (0.46 – 0.74). No obvious correlations between APT, L/V ratio, and PD duration were detected. The D/P creatinine of the 11 patients was maintained at a favorably low value, comparable with that of the other 99 patients. ♦ Conclusions: Peritoneal dialysis therapy using biocompatible dialysate in conjunction with modification of clinical practice may minimize the progression of peritoneal interstitial sclerosis and hyalinizing vasculopathy, preserving favorable peritoneal function for more than 3 years.

Effects of nocturnal oxygen therapy on sleep apnea syndrome in peritoneal dialysis patients.

UNLABELLED Sleep apnea syndrome (SAS) is common in patients with end-stage renal disease (ESRD). Although the treatment of choice is continuous positive airway pressure (CPAP) particularly for obstructive SAS, long-term compliance is not satisfactory. We investigated the effectiveness of nocturnal oxygen therapy on sleep apnea and autonomic nervous dysfunction in peritoneal dialysis (PD) patients with SAS. METHODS 40 patients on PD in our outpatient clinic were screened for SAS by pulse oximetry. We set the indication for nocturnal oxygen therapy at 4% oxygen desaturation index (4% ODI; defined as the number of falls of oxygen saturation > or = 4% per hour) > 5 or average nocturnal saturation < 95%. For SAS patients, 2 l per minute of oxygen was given during sleep and polysomnography was performed before and 1 month after oxygen administration. The heart rate variability was analyzed to assess autonomic nervous activity. RESULTS 23 patients fulfilled the indication for oxygen therapy and 11 patients agreed to participate in the study. After oxygen therapy, the apnea-hypopnea index (AHI) and the frequencies of hypopnea and central apnea were significantly decreased (AHI: from 31.1 +/- 8.8 to 12.7 +/- 8.5, p < 0.01; hypopnea: from 19.5 +/- 4.3 to 3.5 +/- 3.2, p < 0.01; central apnea: from 4.0 +/- 4.0 to 0.8 +/- 1.2, p < 0.05), whereas that of obstructive apnea was not changed. An analysis of heart rate variability showed that oxygen therapy did not alter autonomic activity after 1 month of oxygen therapy. CONCLUSIONS Nocturnal oxygen therapy decreases hypopnea and central apnea in PD patients with SAS. Nocturnal oxygen therapy may be useful for the treatment of SAS in PD patients, particularly when central apnea and hypopnea are predominant.

Peritoneal Fixation Prevents Dislocation of Tenckhoff Catheter

In addition, to reduce the risk of prosthesis slippage and possible bowel erosions, the mesh was trimmed to f it along the peritoneal reflection on the triangular ligament so as to be smaller than the liver and was then secured to the diaphragmatic surface using tack-like fasteners. The problem with left-side hydrothorax (a rare occurrence, accounting for fewer than 10% of cases) is that the mesh would inevitably come into contact with the stomach or the colon, hampering the use of a non-absorbable mesh. A valid option to extend our technique to a leftside hydrothorax would be the use of an absorbable mesh. But such considerations may be debatable because of the small number of cases to be managed. Two patients had early recurrence of hydrothorax after resumption of PD. Because of their poor condition, they were not proposed for thoracoscopic exploration and were switched to hemodialysis treatment. These failures might be explained by the presence of an accompanying missed defect or by insufficient adhesion between the mesh and the liver.

Eearly Partial Re-implantation of Tenckhoff Catheters to Treat Intractable Exit-Site or Tunnel Infection

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Pegylated interferon alpha-2a monotherapy in a peritoneal dialysis patient with chronic hepatitis C

Background: Although pegylated interferon (PEG-IFN) is now the standard treatment for chronic hepatitis C, there are few reports targeting dialysis patients and treatment protocol for hepatitis C virus (HCV) infection has not been determined, particularly in patients on peritoneal dialysis. Case: A 34-year-old woman with chronic hepatitis C started peritoneal dialysis because of progressive renal disease 2 years after peripheral blood stem cell transplantation for aplastic anaemia. The regimen was a single 6-h dwell of 2L glucose dialysate. Considering that her HCV genotype was 2a and that she was a candidate for cadaveric kidney transplant, we decided to treat her with PEG-IFN alpha-2a monotherapy 1 year after the beginning of peritoneal dialysis. We adopted a dose escalation strategy to minimize the total amount of PEG-IFN administration, thereby reducing the risk of adverse effects. Her HCV-RNA disappeared at the 17th week and sustained virus response was achieved thereafter. Only minor side effects were observed including flu-like symptoms and mild anaemia, and residual renal function remained stable during the treatment of 48 weeks (renal Kt/V; from 1.28 to 1.26). Conclusion: PEG-IFN monotherapy with dose modification may be a safe and effective treatment for HCV infection in patients undergoing peritoneal dialysis.

Computed tomography for the management of exit-site and tunnel infections in peritoneal dialysis patients .

PURPOSE To evaluate the effectiveness of computed tomography (CT) for detection of exit-site and tunnel infections with a Tenckhoff catheter. MATERIALS AND METHODS The study enrolled patients with exit-site or tunnel infections who underwent ultrasonography (US), CT scans, and subsequent catheter removal or partial catheter reimplantation from 2010 to 2014. Control cases on peritoneal dialysis who underwent abdominal CT scans for other reasons were randomly selected. Attenuation of the soft tissue around the Tenckhoff catheter was measured in Hounsfield units (HU). RESULTS 9 infected cases and 15 control cases were identified. CT showed increased attenuation around the catheter in all cases, while ultrasonography detected a hypoechoic area only in one case with abscess formation. Maximal attenuation of the inflamed soft tissue was high (median, 36 HU) compared with normal fatty tissue (median, -75 HU). In all cases, one or two sites with increased fat density were observed focally along the catheter, and these areas did not always extend directly from the exit site. CONCLUSIONS In this retrospective study comprising a small number of cases, increased attenuation of fatty tissue around the Tenckhoff catheter correlated with exit-site or tunnel infections. CT might be an auxiliary tool for diagnosis, although CT costs much more than US and is not always available in general practice. Further prospective studies are needed.
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SARCOPENIA AND FRAILTY IN PD: IMPACT ON MORTALITY, MALNUTRITION, AND INFLAMMATION

Background: It is known that sarcopenia is related to malnutrition-inflammation-atherosclerosis (MIA) syndrome and is an important problem in dialysis patients. The notion of frailty includes various physical, psychological, and social aspects. Although it has been reported that sarcopenia is associated with poor prognosis in patients with hemodialysis, reports on peritoneal dialysis (PD) patients are rare. In this study, we examined the morbidity and mortality of sarcopenia and frailty in PD patients. We also investigated the MIA-related factors. Methods: We evaluated 119 patients cross-sectionally and longitudinally. The Asian Working Group for Sarcopenia criteria and the Clinical Frailty Scale (CFS) were used to diagnose sarcopenia and frailty. The primary outcome is all-cause mortality with sarcopenia and frailty. The secondary outcome is the relationship between various MIA-related factors. Results: Morbidity of sarcopenia and frailty in PD patients was 8.4% and 10.9%, respectively. Old age, high values of Barthel Index, Charlson Comorbidity Index, CFS, and low values of body mass index (BMI), muscle strength, muscle mass, and slow walking were associated with sarcopenia. Interleukin-6, albumin, and prealbumin were significantly correlated with muscle mass. During follow-up, the presence of sarcopenia or frailty was associated with the risk of mortality. In multivariate analysis, CFS was related to the mortality rate of PD patients. Conclusions: The presence of sarcopenia or frailty was associated with a worse prognosis.

HOSPITAL-VOLUME EFFECTS ON PERIOPERATIVE OUTCOMES IN PERITONEAL DIALYSIS CATHETER IMPLANTATION: ANALYSIS OF 2,505 CASES

Background: Evidence regarding volume-outcome effects on peritoneal dialysis (PD) catheter implantation is limited. This study aimed to investigate associations between hospital volume (annual caseload of catheter implantation) and perioperative outcomes. Methods: Clinical data for patients who underwent PD catheter implantation from 2007 to 2012 were extracted from the Japanese nationwide Diagnosis Procedure Combination database. Hospital volume was divided into tertiles: low-volume (1 – 6 cases/year), medium-volume (7 – 13 cases/year), and high-volume (≥ 14 cases/year). Multivariate logistic regression analysis for the occurrence of any adverse events and blood transfusion, and gamma-distributed log-linked linear regression analysis for postoperative length of stay were conducted with explanatory variables of hospital volume, age, sex, Charlson comorbidity index, history of hemodialysis, type of anesthesia, and type of hospital. Results: Among 906, 855, and 744 cases in the low-volume, medium-volume, and high-volume groups, overall adverse events were 10.0%, 7.6%, and 6.0%, transfusion rates were 1.3%, 1.1%, and 0.9%, and median postoperative stays were 12, 10, and 9 days, respectively. In multivariate analyses, compared with the low-volume group, medium-volume and high-volume groups were associated with a lower incidence of overall adverse events (odds ratio [OR] = 0.71, p = 0.058, and OR = 0.59, p = 0.013, respectively) and shorter postoperative stay (% difference = -10.5%, p = 0.023, and % difference = -18.5%, p = 0.001, respectively), while no significant association was detected for transfusion. Conclusions: Less frequent adverse events and shorter stays were observed in higher-volume centers. Inverse volume-outcome relationships in PD catheter implantation were confirmed.

Total Renal Care Approach for Patients with End-Stage Renal Disease

BACKGROUND Advances in dialysis medicine have enabled end-stage renal disease (ESRD) patients to live longer. ESRD patients and their family members experience the illness in everyday life, and patients are required to manage their own disease to live longer. Psychological flexibility benefits a person and leads to healthier outcomes. Constructing an independent-minded attitude toward their lives with ESRD is preferably needed. SUMMARY Holistic care is needed to see patients with ESRD and their families because they are faced with life-long illness. From the scholastic standpoint, integration of natural science and humanities is needed. After some collaboration with philosophers, sociologists, and cognitive behavioral therapists, we propose a practical method which we call the total renal care (TRC) approach. With the TRC approach, we help patients and their families by adopting a psychosocial educational approach according to the stage of attitude toward their life with ESRD. In the predialysis care and even in the end-of-life process, selection of therapy based on the individual patients life and their viewpoints on family care burden are important. This enables patients and their families to make selections for renal replacement therapy including home dialysis, renal transplantation, and dialysis discontinuation, as well as hemodialysis and peritoneal dialysis. Key Messages: ESRD is a lifelong disease, and acquiring psychological flexibility would benefit patients and lead to healthier outcomes. Sharing the notion of TRC with their caregivers would strengthen this.

Baseline and Time-Averaged Values Predicting Residual Renal Function Decline Rate in Japanese Peritoneal Dialysis Patients

Residual renal function (RRF) is a strong prognostic factor of morbidity and mortality in patients undergoing peritoneal dialysis (PD). We determined predictors of the RRF rate of decline using both baseline values and time‐averaged ones. We retrospectively analyzed 94 patients being treated with PD at the Japanese Red Cross Medical Center. The decline rate of RRF was calculated by a diminution in the weekly renal Kt/V between the first and last follow up divided by follow‐up years. The mean follow‐up period was 2.28 years, and the mean decline rate of weekly renal Kt/V was 0.25 per year. A multivariate analysis using baseline parameters identified dialysis‐to‐plasma ratios of creatinine at 4 h (P = 0.02), urinary protein (P = 0.02), and mean blood pressure (MBP) (P < 0.01) as being positively associated with the RRF rate of decline, while the use of angiotensin converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) had a negative correlation (P = 0.03). When using time‐averaged values as independent variables, a lower weekly total renal Kt/V (P < 0.0001), higher urinary protein (P < 0.0001), and higher MBP (P = 0.04) independently predicted a faster RRF rate of decline. We demonstrated that PD patients with a lower MBP and lower urinary protein both at baseline and throughout their PD duration had a slower RRF rate of decline. We recommend strict control of blood pressure and anti‐proteinuric therapy for PD patients.