Mild sodium reduction in peritoneal dialysis solution improves hypertension in end stage kidney disease: a case-report study

Introduction Blood Pressure (BP) control is largely unsatisfied in End Stage Kidney Disease (ESKD) principally due to sodium retention. Peritoneal Dialysis (PD) is the most common type of home dialysis, using a peritoneal membrane to remove sodium, though sodium removal remains challenging. Methods This is a case-study reporting two consecutive ESKD patients treated by a novel peritoneal PD solution with a mildly reduced sodium content (130 mmol/L) to treat hypertension. Results In the first case, a 78-year-old woman treated by Continuous Ambulatory PD (CAPD) with standard solution (three 4 h-dwells per day 1.36% glucose 132 mmol/L) showed resistant hypertension confirmed by ambulatory blood pressure monitoring (ABPM), reporting 24 h-BP: 152/81 mmHg, day-BP:151/83 mmHg and night-ABP: 153/75 mmHg, with inversion of the circadian systolic BP rhythm (1.01), despite use of three anti-hypertensives and a diuretic at adequate doses. No sign of hypervolemia was evident. We then switched from standard PD to low-sodium solution in all daily dwells. A six-months low-sodium CAPD enabled us to reduce diurnal (134/75 mmHg) and nocturnal BP (122/67 mmHg), restoring the circadian BP rhythm, with no change in ultrafiltration or residual diuresis. Diet and drug prescription were unmodified too. The second case was a 61-year-old woman in standard CAPD (three 5 h-dwells per day) suffering from hypertension confirmed by ABPM (mean 24 h-ABP: 139/84 mmHg; mean day-ABP:144/88 mmHg and mean night-ABP:124/70 mmHg). She was switched from 132-Na CAPD to 130-Na CAPD, not changing dialysis schedule. No fluid expansion was evident. During low-sodium CAPD, antihypertensive therapy (amlodipine 10 mg and Olmesartan 20 mg) has been reduced until complete suspension. After 6 months, we repeated ABPM showing a substantial reduction in mean 24 h-ABP (117/69 mmHg), mean diurnal ABP (119/75 mmHg) and mean nocturnal ABP (111/70 mmHg). Ultrafiltration and residual diuresis remained unmodified. No side effects were reported in either cases. Conclusions This case-report study suggests that mild low-sodium CAPD might reduce BP in hypertensive ESKD patients.

MO717EFFECT ON BLOOD PRESSURE OF UNCOMPENSATED 130 MM SODIUM DIALYSATE IN CAPD PATIENT WITH RESISTANT HYPERTENSION

Background and Aims In peritoneal dialysis (PD) blood pressure (BP) control is largely unsatisfied mainly due to sodium retention. Currently, sodium removal in PD patients depends substantially on ultrafiltration. Lowering sodium in PD solution might improve sodium removal by diffusion, though the real benefit of low PD solution remains still undetermined. Method In this case report, we used a novel uncompensated glucose-based PD solution (DextroCore LS, Iperboreal Pharma, Italy) containing 130 mM sodium to treat resistant hypertension in 78-year-old female treated by CAPD (3 dwells glucose 1.5% a day, Na 132). Results At baseline, Ambulatory BP monitoring (ABPM) showed 24h-BP (152/81 mmHg), diurnal BP (151/83 mmHg) and nocturnal BP (153/75 mmHg), with inversion of circadian rhythm in systolic BP (systolic night/day ratio: 1.02), despite the use of three anti-hypertensive (doxazosin 4mg, amlodipine 10 mg, telmisartan 80 mg) and diuretic (furosemide 250 mg) at adequate doses. She had no signs of hypervolemia. We switched from standard PD (132 mM/L) to low sodium PD solution using 1.5% glucose bags with sodium concentration of 130 mM. CAPD schedule was confirmed. Second ABPM after six months reported a reduction 24h BP (131/73 mmHg), diurnal (134/75 mmHg) and nocturnal BP (122/67 mmHg), with restoring of circadian BP rhythm. No change in body weight, UF and residual diuresis was found. Diet and therapy prescriptions were unmodified. No side effects were reported. Conclusion Six-months PD treatment with uncompensated glucose-based PD solution containing 130 mM sodium in all daily dwells has allowed to reduce systolic BP (-16 mmHg) in a CAPD patient affected by resistant hypertension, with no change in ultrafiltration and residual diuresis.

MO700EPIDEMIOLOGICAL ADMISSIONS IN PERITONEAL DIALYSIS IN A SINGLE DIALYSIS CENTER

Background and Aims The knowledge of the impact of peritoneal dialysis (PD) program in terms of hospitalization rate can provide solid guidance for nephrologists for management purpose. In a historical cohort of adult PD patients, we examined the hospitalization rates and causes of hospital admissions. Method One hundred ninety-one consecutive PD patients between January 1st 2000 to December 31st 2018 were enrolled. The maximum follow up was 194 months. Their mean age was 65±15 years, 110 were males, 56 had co-morbidities and 67 were diabetics. The median PD vintage was 35 months (interquartile range 20-63 months). Results During the follow-up, 163 out of 191 patients (85%) underwent hospital admission for a total of 356 hospitalizations [57 hospitalizations per 100-person-years]. The most frequent cause of admission was infection (20 hospitalizations per 100-person-years) mainly due to peritonitis (12 hospitalizations per 100-person-years) followed by cardiovascular diseases (17 hospitalizations per 100-person-years). Hospitalizations due to miscellaneous causes were 21 per 100-person-years. In the whole group, high NYHA score [Incidence Rate Ratio (IRR): 1.52, 95%CI 1.21-1.89, P<0.001], residual diuresis <500 ml/die (IRR: 1.43, 95%CI 1.13-1.82, P=0.002), malnutrition (IRR: 1.47, 95%CI 1.08-1.99, P=0.01) and older age (>65 years) (IRR 1.26, 95%CI 1.02-1.56, P=0.03) and were associated to all-cause hospitalizations. In an analysis by hospitalization type, the factors related to admission for infection diseases was malnutrition (IRR: 1.91, 95%CI 1.16-3.03, P=0.005) and high NYHA score (IRR: 1.52, 95%CI 1.03-2.22, P=0.02). As expected, hospitalizations due to cardiovascular causes were strongly related to older age (>65 years) (IRR 2.02, 95%CI 1.35-3.03, P<0.001), diabetes (IRR 2.13, 95%CI 1.43-3.18, P<0.001), high NYHA score (IR 2.14, 95%CI 1.43-3.21, P=0.001], residual diuresis <500 ml/die (IRR: 1.65, 95%CI 1.06-2.55, P=0.02) and previous cardiovascular events (IRR: 1.50, 95%CI 0.98-2.25, P=0.05). Conclusion Analyzing the causes and the rate of hospitalization in PD patients allows more accurate management of these high risk category of patients and contributes to a more efficient organization of a renal department.

Beta-trace protein as a potential biomarker of residual renal function in patients undergoing peritoneal dialysis

Background Residual renal function is closely linked to quality of life, morbidity and mortality in dialysis patients. Beta-trace protein (BTP), a low molecular weight protein, has been suggested as marker of residual renal function, in particular in patients on hemodialysis. We hypothesized that BTP also serves as a marker of residual renal function in pertioneal dialysis patients. Methods In this study 34 adult patients on peritoneal dialysis were included. BTP, creatinine, cystatin C and urea concentrations were analyzed simultaneously in serum and dialysate to calculate renal and peritoneal removal of the analytes. Results In peritoneal dialysis patients with residual diuresis, mean serum BTP was 8.16 mg/l (SD ± 4.75 mg/l). BTP correlated inversely with residual diuresis (rs = − 0.58, p < 0.001), residual creatinine clearance (ClCr) (rs = − 0.69, p < 0.001) and total urea clearance (Clurea) (rs = − 0.56, p < 0.001). Mean peritoneal removal of BTP was 3.36 L/week/1.73m2 (SD ± 1.38) and mean renal removal 15.14 L/week/1.73m2 (SD ± 12.65) demonstrating a significant renal contribution to the total removal. Finally, serum BTP inversely correlated with alterations in residual diuresis (r = − 0.41, p = 0.035) and renal creatinine clearance over time (r = − 0.79, p = p < 0.001). Conclusion BTP measurement in the serum may be a simple tool to assess residual renal function in peritoneal dialysis patients.

Poor correlation between meropenem and piperacillin plasma concentrations and delivered dose of continuous renal replacement therapy

There is insufficient data on the relationship between antibiotic dosing and plasma concentrations in patients treated with continuous renal replacement therapy (CRRT). In this prospective observational study, we explored the variability in plasma concentrations of meropenem and piperacillin in critically ill patients treated with CRRT and the correlation between concentrations and CRRT intensity. Antibiotic concentrations were measured at the mid and end of the dosing interval and repeated after 2-3 days when feasible. Measured concentrations were compared to the clinical susceptible breakpoints for Pseudomonas aeruginosa, 16 and 2 mg/L for piperacillin and meropenem respectively. CRRT intensity was estimated by delivered, time-averaged, total effluent flow (Qeff), corrected for predilution. Concentrations were also compared between patients with different residual diuresis. We included 140 meropenem concentrations from 98 patients and 47 piperacillin concentrations from 37 patients. Concentrations at the mid of the dosing interval were above target at all occasions for both antibiotics. For meropenem, 6.5% of trough concentrations were below target, for piperacillin 22%. Correlations between Qeff and antibiotic concentrations or concentration T½ were either statistically not significant or weak. Meropenem concentrations and T½ differed between patients with different residual diuresis. Thus, when treating ICU patients with CRRT and recommended doses of meropenem or piperacillin, both low, suboptimal, and unnecessary high, potentially toxic, plasma concentrations are common. Plasma concentrations cannot be predicted from CRRT intensity. Residual diuresis is associated with lower meropenem concentrations, but the correlation is weak. Concentration measurements is likely the most useful approach to avoid suboptimal treatment.

Multi-Method Complex Approach for Hydration Assessment Does Not Detect a Hydration Difference in Hemodialysis versus Peritoneal Dialysis Patient

Assessment of hydration status is essential in monitoring the effectiveness of renal replacement therapy and is usually based on physical examination. However, comparisons of hydration status achieved with different dialysis methods are not conclusive. We compared the hydration status of patients on chronic hemodialysis (HD, n = 60) and peritoneal dialysis (PD, n = 20) in a comprehensive assessment including physical examination and additional methods. The mean age of the 80 chronically dialyzed patients (53 males, 27 females) was 58.1 ± 13.9 years. The clinical evaluation took into account the presence of peripheral edema, dyspnea, and crackling over the lung fields. Additional tests included lung ultrasound, electrical bioimpedance (performed in 79 patients), impedance cardiography, ultrasound assessment of large abdominal vessels (performed in 79 patients), select echocardiographic parameters (obtained in 78 patients), and serum NT-proBNP concentration. Residual diuresis volume was significantly higher in the PD group. We found no significant differences between the two groups in any other baseline characteristics or in the results of the clinical examination or additional tests. The use of different methods for assessing hydration does not allow differentiation of patients treated with dialysis in terms of the dialysis technique used. Therefore, it seems reasonable to use common algorithms to objectify the hydration status of these patients.

Survival of Patients on Hemodialysis with Erectile Dysfunction

Background and objectives: In patients on hemodialysis, erectile dysfunction is an independent mortality factor. This study aimed to determine the risk factors that affect the survival of hemodialysis patients with erectile dysfunction. Materials and Methods: During a seven-year period, erectile dysfunction was identified among the fatalities reported in patients receiving chronic hemodialysis, on the basis of the International Index of Erectile Function questionnaire. The study covered 70 patients of mean age 57 ± 6.7 years. During the examined period, 42 (60%) patients died at the mean age 57 ± 6.8 years. The study was completed by 28 (40%) patients, aged 57 ± 6.55 years. Laboratory, demographic, anthropometric, and clinical characteristics were recorded using standard methods. Results: Statistically significant differences between the two groups of respondents were found concerning dialysis duration (p < 0.001), number of leukocytes (p = 0.003), adequacy of hemodialysis (p = 0.004), intima media thickness of the carotid artery (p < 0.001), presence of cardiovascular disease (p = 0.03), residual diuresis (p = 0.04), and hemodiafiltration (p < 0.001). Hemodialysis adequacy (B = −9.634; p = 0.017), intima media thickness (B = 0.022; p = 0.003), residual diuresis (B = −0.060; p = 0.007), and lower rates of cardiovascular disease (B = 0.176; p = 0.034) were significant survival predictors among our patients with erectile dysfunction. Conclusions: Risk factors that are associated with improved survival of patients on hemodialysis with erectile dysfunction in our study are: preserved diuresis, high-quality hemodialysis, lower incidence of cardiovascular disease, and less thickening of the intima media of the carotid arteries.

P1212PREDICTORS OF QUALITY OF LIFE IN PERITONEAL DIALYSIS: A SINGLE-CENTER EXPERIENCE

Background and Aims Quality of life (QoL) is an important indicator of quality of healthcare. Measuring QoL and its correlates for peritoneal dialysis (PD) patients is very important for intervention and clinical decision-making. Being a technique performed by the patients themselves, their perspective of health related QoL is extremely important. The EuroQol questionnaire evaluates 5 QoL dimensions (mobility, self-care, usual activities, pain/ discomfort and anxiety/ depression) and includes a visual analogue scale (VAS) rated 0-100% that provides a quantitative measure of the patients’ perception of their overall health. Method Data from 69 patients on peritoneal dialysis at our center were collected using EQ-5D-5L EuroQol questionnaire. Health state index (HSI) scores were calculated from individual health profiles using the Spanish value set (maximum score 1). Additional clinical and laboratory data was collected from the patient’s medical files. Results Mean age of the population studied was 55,2 ± 14,0 years, and 66,7% (n=46) were male. Most patients were on PD &gt; 1 year (62,3%, n=43) and performing automated peritoneal dialysis (APD) (52,2%, n=36). Mean HSI was 0,88 ± 0,15 and mean VAS score was 75,1 ± 18,7. Patients with weekly Kt/V ≥ 1,7 scored on average 0,09 points higher on the HSI (p=0,070) and 13,34 points higher in VAS (p=0,019), compared to patients with weekly Kt/V &lt; 1,7. Patients on PD &gt; 1 year scored on average 0,09 points lower on the HSI (p=0,017), mainly due to higher levels of anxiety/depression, and 11,9 points lower in VAS (p=0,005) than those &lt; 1 year. Age did not significantly influence QoL, even when comparing patients &gt; 70 years with those &lt; 70 years old (HSI 73.0 ± 15.5 vs 75.4 ± 19.3, p=0.710 / VAS 0.82 ± 0.3 vs 0.89 ± 0.1, p=0.175). Likewise, when comparing continuous ambulatory peritoneal dialysis (CAPD) to APD, there was no significant difference in the scores of QoL. Gender, diabetes mellitus, arterial hypertension, cancer and infectious events related to PD in the last year did not influence QoL. Residual diuresis as an isolated factor did not significantly influence QoL scores. However, as it is a fundamental contributor to Kt/V, it may be indirectly associated with better QoL. A more detailed analysis was not possible as the number of patients with Kt/V ≥ 1.7 and no residual diuresis was, as expected, very low (n=4). Conclusion Perceived QoL in the elderly when compared to younger patients in PD was not inferior in our study, showing this option should be discussed individually with each patient. Our results revealed time in PD negatively influences patients’ perception of their own health, which may be due to patient’s burden and exhaustion, and eventually lead to technique related complications. Kt/V ≥ 1,7 was related to better QoL, either because higher dialysis adequacy leads to better QoL, or because patients who feel better have less tendency to neglect the technique. Finally, we also found type of PD (CAPD vs APD) to have no significant influence on QoL, reinforcing the idea that it should be discussed and adapted to each individual patient.

Glucose Exposure in Peritoneal Dialysis Is a Significant Factor Predicting Peritonitis

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.