The Association between Glucose Exposure and the Risk of Peritonitis in Peritoneal Dialysis Patients

Background and objective Little or no clinical evidence is available on the association between glucose exposure and peritoneal host defense in peritoneal dialysis (PD) patients. The objective of the present study was to quantify the exposure to glucose during the first year on PD and investigate the association with subsequent peritonitis. Methods We analyzed prospectively collected demographic and peritonitis data from incident adult PD patients between 1990 and 2010. For the present study, we conducted a review of both in- and outpatient medical records of all patients to obtain their day-to-day dialysis schemes during the first year on PD. From these data, the average exposure to glucose was quantified. The exposure was stratified into low- and high-glucose groups based on the median, analyzed per standard deviation and in quartiles. Cox proportional hazard models were used to calculate crude and adjusted hazard ratios (HRs) and 95% confidence intervals for the association between glucose exposure and peritonitis. Adjustments were made for age, sex, primary kidney disease, diabetes mellitus, Davies comorbidity score and the treatment period. Results In total, 230 patients were included in the study of whom 151 (66%) experienced a first peritonitis episode. The median follow-up time was 2.6 years (interquartile range [IQR]: 1.9 – 3.8) in the low-glucose group and 3.1 (IQR: 2.1 – 4.2) in the high-glucose group. After adjustment for confounding factors, no association between high glucose exposure and the risk of peritonitis was found (HR: 0.81; 0.55 – 1.17). No association was present when glucose exposure was analyzed per standard deviation (SD) (HR: 0.98; 0.79 – 1.21) or patient quartiles were applied. No association was identified between glucose exposure and severe peritonitis, Staphylococcus aureus peritonitis, or a peritonitis episode that lasted more than 14 days. Conclusions Exposure to glucose is not associated with an increased risk of peritonitis. The equilibrium between glycemic harm to peritoneal host defense and detrimental effects of glucose on invading microorganisms may determine the susceptibility to peritoneal infection.

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Association between Peritoneal Glucose Exposure and Peritonitis in Peritoneal Dialysis Patients: TheBalANZ Trial

Peritoneal Dialysis International ◽

10.3747/pdi.2016.00263 ◽

2017 ◽

Vol 37 (4) ◽

pp. 407-413 ◽

Cited By ~ 1

Author(s):

Melissa Nataatmadja ◽

Yeoungjee Cho ◽

Elaine M. Pascoe ◽

Darsy Darssan ◽

Carmel M. Hawley ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Peritoneal Dialysis ◽

High Glucose ◽

Controlled Trial ◽

Exposure Group ◽

Peritoneal Membrane ◽

Randomized Controlled ◽

Increased Risk ◽

Low Glucose ◽

Glucose Exposure

BackgroundGlucose is the primary osmotic medium used in most peritoneal dialysis (PD) solutions, and exposure to glucose has been shown to exert detrimental effects both locally, at the peritoneal membrane, and systemically. Moreover, high dialysate glucose exposure may predispose patients to an increased risk of peritonitis, perhaps as a result of impaired host defences, vascular disease, and damage to the peritoneal membrane.MethodsIn this post-hoc analysis of a multicenter, multinational, open-label randomized controlled trial of neutral pH, low-glucose degradation product (GDP) versus conventional PD solutions ( balANZ trial), the relationship between peritonitis rates of low (< 123.1 g/day) versus high (≥ 123.1 g/day) dialysate glucose exposure was evaluated in 177 incident PD patients over a 2-year study period.ResultsPeritonitis rates were 0.44 episodes per patient-year in the low-glucose exposure group and 0.31 episodes per patient-year in the high-glucose exposure group, (incidence rate ratio [IRR] 0.69, p = 0.09). There was no significant association between dialysate glucose exposure and peritonitis-free survival on univariable analysis (high glucose exposure hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.40 –1.08) or on multivariable analysis (adjusted HR 0.64, 95% CI 0.39 – 1.05). Moreover, there was no relationship between peritoneal glucose exposure and type of organism causing peritonitis. Physician-rated severity of first peritonitis episodes was similar between groups, as was rate and duration of hospital admission.ConclusionsOverall, this study did not identify an association between peritoneal dialysate glucose exposure and peritonitis occurrence, severity, hospitalization, or outcomes. A further large-scale, prospective, randomized controlled trial evaluating patient-level outcomes is merited.

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The Influence of Initial Peritoneal Transport Characteristics, Inflammation, and High Glucose Exposure on Prognosis for Peritoneal Membrane Function

Peritoneal Dialysis International ◽

10.3747/pdi.2011.00137 ◽

2012 ◽

Vol 32 (6) ◽

pp. 636-644 ◽

Cited By ~ 12

Author(s):

M. José Fernández-Reyes ◽

M. Auxiliadora Bajo ◽

Gloria Del Peso ◽

Marta Ossorio ◽

Raquel Díaz ◽

...

Keyword(s):

Mass Transfer ◽

Peritoneal Dialysis ◽

High Glucose ◽

Peritoneal Membrane ◽

Transfer Coefficients ◽

High Exposure ◽

Membrane Function ◽

Peritoneal Transport ◽

Fast Transport ◽

Glucose Exposure

♦ BackgroundFast transport status, acquired with time on peritoneal dialysis (PD), is a pathology induced by peritoneal exposure to bioincompatible solutions. Fast transport has important clinical consequences and should be prevented.♦ ObjectiveWe analyzed the repercussions of initial peritoneal transport characteristics on the prognosis for peritoneal membrane function, and also whether the influence of peritonitis and high exposure to glucose are different according to the initial peritoneal transport characteristics or the moment when such events occur.♦ MethodsThe study included 275 peritoneal dialysis patients with at least 2 peritoneal function studies (at baseline and 1 year). Peritoneal kinetic studies were performed at baseline and annually. Those studies consist of a 4-hour dwell with glucose (1.5% during 1981 – 1990, and 2.27% during 1991 – 2002) to calculate the peritoneal mass transfer coefficients of urea and creatinine (milliliters per minute) using a previously described mathematical model.♦ ResultsMembrane prognosis and technique survival were independent of baseline transport characteristics. Fast transport and ultrafiltration (UF) failure are reversible conditions, provided that peritonitis and high glucose exposure are avoided during the early dialysis period. The first year on PD is a main determining factor for the membrane's future, and the mass transfer coefficient of creatinine at year 1 is the best functional predictor of future PD history. After 5 years on dialysis, permeability frequently increases, and UF decreases. Icodextrin is associated with peritoneal protection.♦ ConclusionsPeritoneal membrane prognosis is independent of baseline transport characteristics. Intrinsic fast transport and low UF are reversible conditions when peritonitis and high glucose exposure are avoided during the early dialysis period. Icodextrin helps in glucose avoidance and is associated with peritoneal protection.

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Strategies to Reduce Glucose Exposure in Peritoneal Dialysis Patients

Peritoneal Dialysis International ◽

10.1177/089686080002002s08 ◽

2000 ◽

Vol 20 (2_suppl) ◽

pp. 37-41 ◽

Cited By ~ 61

Author(s):

Clifford J. Holmes ◽

Ty R. Shockley

Keyword(s):

Amino Acids ◽

Peritoneal Dialysis ◽

High Glucose ◽

Degradation Products ◽

Dialysis Patients ◽

Carbohydrate Absorption ◽

Glucose Degradation Products ◽

Osmotic Agent ◽

Glucose Exposure

Glucose has been used successfully for more than two decades in peritoneal dialysis, and in this regard, must be considered a safe and effective osmotic agent. Recently, however, insight has been growing about the potential for metabolic and peritoneal effects arising from long-term exposure to high glucose concentrations—for example, hyperlipidemia and loss of peritoneal ultrafiltration. Clinical concerns over exposure to excessive glucose and glucose degradation products (GDPs) during peritoneal dialysis can be significantly ameliorated by the use of non-glucose-based peritoneal dialysis (PD) solutions, in combination with more biocompatible glucose-based formulations. Peritoneal exposure to GDPs can be reduced by using low-GDP-containing glucose formulations and non glucose solutions such as amino acids and icodextrin. Peritoneal glucose exposure, hyperosmolar stress, and carbohydrate absorption can be reduced by using a combination of icodextrin and amino acids.

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A Comparison between Intermittent Peritoneal Dialysis and Automatic Peritoneal Dialysis on Urgent Peritoneal Dialysis

American Journal of Nephrology ◽

10.1159/000477178 ◽

2017 ◽

Vol 45 (6) ◽

pp. 540-548 ◽

Cited By ~ 4

Author(s):

Chang Wang ◽

Xiao Fu ◽

Yuan Yang ◽

Jun Deng ◽

Hong-qing Zhang ◽

...

Keyword(s):

Peritoneal Dialysis ◽

First Year ◽

Mechanical Complication ◽

Chi Square ◽

Technique Survival ◽

Mechanical Complications ◽

Increased Risk ◽

Significant Difference ◽

Chi Square Test ◽

Feasible Alternative

Background: Urgent-start dialysis is a major problem for incident dialysis population. Urgent start on hemodialysis is associated with an increased risk of infectious or mechanical complications, and its mortality is equal to or higher than that of urgent start on peritoneal dialysis (PD). However, compared to patients starting PD in a planned setting, those on urgent-started PD have an increased risk of mechanical complications and lower technique survival. Methods: In this study, 101 adult incident dialysis patients (≥18 years old) who underwent Tenckhoff catheter implantation were enrolled. All of the patients were grouped according to the urgent PD mode: the intermittent PD (IPD) or automatic PD (APD) group, and patients were followed for 1 year. The paired or independent t test was used to analyze the change of laboratory variables. Pearson chi-square test was applied to compare the short outcome between the 2 groups. Results: When PD was treated for 7 days and 1 month, the APD group has the lower serum potassium and phosphorus levels than the IPD group. The incidence of catheter dysfunction was significantly lower in the APD group. The morbidity of infection associated with PD in the first year was lower in the APD group despite no significant difference existing. The technique survival and patient survival rate have no evident difference between the 2 groups. Conclusion: Compared to IPD, urgent start on APD could reduce the risk of mechanical complication, which could be considered a gentle, safe, and feasible alternative to urgent start on IPD.

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Ultrafiltration and Dialysis Adequacy with Various Daily Schedules of Dialysis Fluids

Peritoneal Dialysis International ◽

10.3747/pdi.2011.00048 ◽

2012 ◽

Vol 32 (5) ◽

pp. 545-551 ◽

Cited By ~ 3

Author(s):

Ramón Paniagua ◽

Malgorzata Debowska ◽

María-De-Jesús Ventura ◽

Marcela Ávila–Díaz ◽

Carmen Prado–Uribe ◽

...

Keyword(s):

Peritoneal Dialysis ◽

High Glucose ◽

Dialysis Fluid ◽

Dialysis Adequacy ◽

Mean Values ◽

Fluid Removal ◽

Glucose Exposure ◽

The Mean ◽

Dialysis Fluids ◽

Small Solute

Dialysis regimens for continuous ambulatory peritoneal dialysis (CAPD) patients vary with the need for fluid removal, but also because of concerns about the local and systemic consequences of high glucose exposure. The implications of various regimens for dialysis adequacy—that is, fluid and small-solute removal—are not always clear. We therefore analyzed ultrafiltration (UF) and adequacy indices for 4 different combinations of dialysis fluid.Collections of 24-hour dialysate and urine were carried out in 99 patients on CAPD. On 4 separate occasions, each patient performed 4 exchanges in 24 hours, including 3 daily exchanges with 1.36% glucose and 1 night exchange with either 1.36% glucose (G1 schedule), 2.27% glucose (G2 schedule), 3.86% glucose (G3 schedule), or icodextrin (Ico schedule). Weekly, total, and dialysis Kt/V and KT were calculated for both urea and creatinine.The mean values of urea Kt/V and KT were significantly lower for the G1 schedule than for the G3 and Ico schedules. The adequacy indices for overnight application of 3.86% glucose and icodextrin were similar. Using dialysis fluids with 1.36% and 2.27% glucose overnight reduces glucose exposure, but those schedules may provide inadequate UF and small-solute removal in some patients (UF < 1 L daily, Kt/V < 1.7).

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The Influence of Glucose Exposure Load and Peritoneal Membrane Transport on Body Composition and Nutritional Status Changes after 1 Year on Peritoneal Dialysis

Peritoneal Dialysis International ◽

10.3747/pdi.2016.00265 ◽

2017 ◽

Vol 37 (4) ◽

pp. 458-463 ◽

Cited By ~ 6

Author(s):

Rafaela Siviero Caron-Lienert ◽

Carlos Eduardo Poli-de-Figueiredo ◽

Ana Elizabeth Prado Lima Figueiredo ◽

Bartira Ercília Pinheiro da Costa ◽

Carlo Crepaldi ◽

...

Keyword(s):

Body Composition ◽

Peritoneal Dialysis ◽

Nutritional Status ◽

Membrane Transport ◽

Dry Weight ◽

First Year ◽

Peritoneal Membrane ◽

Tissue Mass ◽

Glucose Exposure ◽

Composition Changes

BackgroundThe characteristics of peritoneal membrane transport differ among patients, affecting the prescription of peritoneal dialysis (PD) modality and glucose exposure in order to achieve an effective dialysis. This study aims to verify the influence of glucose exposure load and peritoneal membrane transport on body composition and nutritional status changes after the first year of PD.MethodsWe examined a cohort of 85 incident PD patients during the first year of treatment. We established a cut-off of 5% to define changes in dry weight (DW), lean tissue mass (LTM), and fat mass (FM).ResultsIn total, 50.6% of the patients presented DW gain, 41.2% showed LTM loss, and 65.9% presented FM gain. Over the time (T0 – T12), we found significant differences in DW, body mass index (BMI), adipose tissue mass (ATM), FM and fat tissue index (FTI). Patients with lower dialysate-to-plasma creatinine ratio showed DW and FM gain. We observed a higher percentage of nonfast transporters in DW gain when comparing with DW no gain. As for glucose exposure load, no body composition changes were seen.ConclusionsMost patients presented DW gain, FM gain, and LTM loss. The characteristics of peritoneal membrane transport affected DW during the first year, changes being greater in nonfast than in fast transporters.

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MO688CALCIUM PHOSPHATE PRODUCT IN PERITONEAL DIALYSIS: A RISK FACTOR FOR TYPE I MEMBRANE FAILURE?

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab101.0010 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

Berfu Korucu ◽

Omer Faruk Akcay ◽

Galip Guz

Keyword(s):

Risk Factor ◽

Peritoneal Dialysis ◽

High Glucose ◽

Cox Regression ◽

Residual Renal Function ◽

Study Endpoint ◽

Type I ◽

Cox Regression Analysis ◽

Increased Risk

Abstract Background and Aims Type I membrane failure (T1MF), increased transport status with ultrafiltration, and solute removal inadequacy are among the most challenging issues in peritoneal dialysis (PD) continuity. Although quite common, the causes of T1MF are not fully understood. This study aims to identify risk factors associated with T1MF. Method This is a retrospective, single site, cohort study of incident adult peritoneal dialysis patients sampled between January 2000 and January 2020. Patients were classified as “increased transporters” who had two or more categories of a rise in peritoneal equilibration test (PET), and “stable transporters” who had had a rise of 1 or no categories from their baseline during follow-up. The four-hour dialysate/plasma creatinine ratio was used to classify PET categories. The study endpoint was five years for stable transporters, and at the time of two category rise in the PET test for increased transporters. Results Baseline demographics, diabetes frequency, residual renal function (RRF), non-phosphate baseline laboratory, parathormone levels, and PD modalities were similar between the increased transporters (n=48) and the stable transporters (n=93). Significantly more patients were using renin-angiotensin-aldosterone system (RAAS) blockers in stable transporters and high-glucose dialysates in increased transporters (p=0.03 and p<0.01). Icodextrin, calcitriol, calcium-based phosphate binder use, and the number of peritonitis episodes were similar between the groups. Increased transporters reached the endpoint in 3.9(±0.7) years. Increased transporters had a higher baseline phosphate than stable transporters (p=0.02). The frequency of patients with an RRF and groups’ mean RRF in ml were similar at the endpoint (p=0.37, p=0.13). Increased transporters had a significantly higher baseline and endpoint CaXP than stable transporters (p<0.01 and p=0.02). Baseline weekly peritoneal Kt/V and peritoneal creatinine clearance (PCrCl) were similar at baseline. Increased transporters had significantly lower endpoint peritoneal Kt/V and insignificantly lower endpoint PCrCl than stable transporters (p<0.01 and p=0.05). ΔUF was negative for increased transporters and positive for stable transporters. Age, diabetes, peritonitis episodes, RAAS blocker use, and PD modality were insignificant in Cox regression analysis. A CaXP of >55 was related to 2.51-fold, and high-glucose dialysates were associated with a 2.93-fold increased risk for a rise in transport status (p=0.01 and p<0.01). Mean follow-up was 7.0 (±3.9) years for stable transporters and 5.6 (±2.0) years for increased transporters. Technical survival was significantly higher in stable transporters (p=0.03). Conclusion Our study revealed a CaXP of >55 is a risk factor for a significant increase in transport status, presumably due to peritoneal calcification. The peritoneal Kt/V, PCrCl, and UF rates declined accordingly. The high-glucose dialysates are associated with a high risk in analyses. However, it is not possible to determine whether these solutions are the cause or the result of Type I membrane failure.

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Glucose Exposure in Peritoneal Dialysis Is a Significant Factor Predicting Peritonitis

American Journal of Nephrology ◽

10.1159/000506324 ◽

2020 ◽

Vol 51 (3) ◽

pp. 237-243

Author(s):

Herma Uiterwijk ◽

Casper F.M. Franssen ◽

Johanna Kuipers ◽

Ralf Westerhuis ◽

Ferdau L. Nauta

Keyword(s):

Peritoneal Dialysis ◽

Regression Models ◽

Cox Regression ◽

Kaplan Meier ◽

Increased Risk ◽

Low Glucose ◽

Glucose Exposure ◽

Prospective Longitudinal ◽

Residual Diuresis

Introduction: Loss of residual renal function (RRF) as well as high peritoneal glucose exposure are associated with increased peritonitis frequency in peritoneal dialysis (PD) patients. Our objective was to investigate the contribution of RRF and peritoneal glucose exposure to peritonitis in PD patients. Methods: In this prospective longitudinal cohort study, 105 incident end-stage renal disease patients that started PD between January 2006 and 2015 were studied. Follow-up was 5 years with censoring at death or switch to another treatment modality. Cox regression models were used to calculate the association between glucose exposure, RRF, and peritonitis. Kaplan-Meier analysis was used to examine the difference in occurrence of peritonitis between patients with high and low glucose exposure and between those with and without residual diuresis. Results: One hundred and five patients were followed for a mean of 23 months. Fifty-one patients developed a peritonitis. Cox regression models at 6 months showed that glucose exposure and not residual diuresis significantly predicted PD peritonitis. Kaplan-Meier analysis after 6 months of follow-up showed that time to first PD peritonitis was significantly longer in the low glucose exposure group. Similarly, patients with RRF had a significantly longer interval to first peritonitis compared to patients without RRF. Conclusion: A higher exposure to glucose rather than loss of RRF is associated with an increased risk of peritonitis. This confirms the detrimental effects of glycemic harm to the peritoneal host defense on invading microorganisms and argues for the use of the lowest PD glucose concentrations possible.

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Sexual Effect of Platelet-to-Lymphocyte Ratio in Predicting Cardiovascular Mortality of Peritoneal Dialysis Patients

Mediators of Inflammation ◽

10.1155/2022/8760615 ◽

2022 ◽

Vol 2022 ◽

pp. 1-9

Author(s):

Hui Sheng ◽

Yagui Qiu ◽

Xi Xia ◽

Chunyan Yi ◽

Jianxiong Lin ◽

...

Keyword(s):

Peritoneal Dialysis ◽

Proportional Hazards ◽

Cox Regression ◽

Cox Proportional Hazards ◽

Hazard Ratios ◽

Increased Risk ◽

Relationship Of ◽

The Relationship ◽

Cvd Mortality

Background. The study is aimed at exploring the relationship of platelet-to-lymphocyte (PLR), all-cause, and cardiovascular disease (CVD) mortality in peritoneal dialysis (PD) patients based on gender. Methods. A total of 1438 PD patients from January 1,2007 to December 31, 2014 in PD center at The First Affiliated Hospital, Sun Yat-sen University, were included. Patients were followed up until December 31, 2019. The endpoint was all-cause mortality and CVD mortality. Cox proportional hazards regression models were used to evaluate the association of PLR with all-cause and CVD mortality to calculate hazard ratios (HR) and 95% confidence intervals (CI). Results. After a median of 48.9 (interquartile range [IQR]: 23.4-79.3) months of follow-up, 406 (28.2%) patients died based on all-cause death, among which 200 (49.3%) patients died from CVD. In the multivariate Cox regression model, we found that PLR was independently related to an increased risk of CVD mortality only in female PD patients, with HR of 1.003 (95% CI: 1.001-1.006). Interaction test showed that the correlation between PLR level for all-cause and CVD mortality varied with gender ( p = 0.042 and p = 0.012 , respectively). Conclusion. Higher PLR was associated with a higher risk of CVD mortality in female PD patients.

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Association of Treated and Untreated Gastroesophageal Reflux Disease in the First Year of Life with the Subsequent Development of Asthma

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18189633 ◽

2021 ◽

Vol 18 (18) ◽

pp. 9633

Author(s):

Anna Cantarutti ◽

Claudio Barbiellini Amidei ◽

Camilla Valsecchi ◽

Antonio Scamarcia ◽

Giovanni Corrao ◽

...

Keyword(s):

Gastroesophageal Reflux Disease ◽

Gastroesophageal Reflux ◽

Reflux Disease ◽

Subsequent Development ◽

First Year ◽

Risk Increase ◽

Hazard Ratios ◽

Increased Risk ◽

First Year Of Life ◽

Clinical Asthma

Introduction: Gastroesophageal reflux disease (GERD) as well as its treatment with acid-suppressive medications have been considered possible risk factors for the development of asthma, but few studies have disentangled the role of GERD with that of its treatment. The present study aimed at estimating the association of treated and untreated GERD in the first year of life with the risk of asthma. Methods: Retrospective cohort study including all children born between 2004 and 2015 registered in Pedianet, an Italian primary care database. We analyzed the association of children exposed to GERD (both treated and untreated) in the first year of life with the risk of developing clinically assessed asthma (clinical asthma) after 3 years. Secondary outcomes included asthma identified by anti-asthmatic medications (treated asthma) and wheezing after 3 years. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated comparing children with and without GERD, stratifying by treatment with acid-suppressive medications. Results: Out of 86,381 children, 1652 (1.9%) were affected by GERD in the first year of life, of which 871 (53%) were treated with acid-suppressive medications. Compared with controls, children with GERD were at increased risk of clinical asthma (HR: 1.40, 95% CI 1.15–1.70). Risks were similar between treated and untreated GERD (p = 0.41). Comparable results were found for treated asthma, but no risk increase was seen for wheezing. Discussion: Early-life GERD was associated with subsequent childhood asthma. Similar risks among children with treated and untreated GERD suggest that acid-suppressive medications are unlikely to play a major role in the development asthma.

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