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Spiritual well-being (SWB), an individual's understanding of the meaning and purpose of life, may help patients with chronic or terminal illnesses cope with their diseases. This study aimed to assess SWB in patients on peritoneal dialysis (PD), as well as its relationship with patient characteristics and patient-reported outcomes (PRO).The data were obtained from questionnaires that formed part of the PD Outcomes and Practice Patterns Study (PDOPPS). Measures used in this study were SWB scores derived from the WHO quality of life, spirituality, religiousness and personal beliefs (WHOQOL-SRPB) tool including 32 items from eight facets; physical (PCS) and mental component summary (MCS) scores of the 12-Item Short-Form Health Survey (SF-12), Center of Epidemiologic Studies Depression Scale-10 (CES-D-10) scores, burden of kidney disease scores and functional status scores.Overall, 529 out of 848 participants (62%) completely responded to the questionnaires and were included in the analysis. Over two-thirds of PD patients (70%) had moderate or higher SWB scores. The SWB scores were significantly lower in patients with age 65 years and unemployed status. SWB scores positively correlated with higher PCS, MCS, burden of kidney disease scores and functional status scores, while negatively correlated with depression scores by CES-D-10 scale. Patients who reported significant depressive symptoms (CES-D-10 score ≥ 10) had significantly lower SWB scores.Better SWB was significantly associated with better health-related QOL (HRQOL) and the absence of depressive symptoms. SWB may be an essential consideration in the delivery of high-quality PD.

Few studies have discussed the role of peritoneal dialysis (PD) in managing acute kidney injury (AKI) in critically ill patients. The present study compares the outcome of AKI in intensive care unit (ICU) patients randomized to treatment with tidal PD (TPD) or continuous venovenous hemodiafiltration (CVVHDF). One hundred and twenty-five ICU patients with AKI were randomly allotted to CVVHDF, (Group A, N = 62) or TPD, (group B, N = 63). Cause and severity of renal injury were assessed at the time of initiating dialysis. The primary outcome was hospital mortality at 28 days, and secondary outcomes were time to recovery of renal function, duration of stay in the ICU, metabolic and fluid control, and improvement of sensorial and hemodynamic parameters. No statistically significant differences were observed between groups in regard to patients' characteristics. The survival at 28 days was significantly better in the patients treated with TPD when compared to CVVHDF (69.8% vs. 46.8%, P < 0.01). Infectious complications were significantly less (P < 0.01) in the TPD group (9.5%) when compared to the CVVHDF group (17.7%). Recovery of kidney function (60.3% vs. 35.5%), median time to resolution of AKI and the median duration of ICU stay of 9 days (7-11) vs. 19 days (13-20) were all in favor of TPD (P < 0.01). This study suggests that there are better outcomes with TPD compared to CRRT in the treatment of critically ill patients with AKI.

The high incidence of depression in end-stage renal disease (ESRD) patients is well documented. Our group and others have estimated that 20-30% of ESRD patients experience major depression. Several recent studies have emphasized the relationship between depressive symptoms and mortality and morbidity in both hemodialysis (HD) and peritoneal dialysis (PD) patients. We screened 380 PD patients for depression using the Beck Depression Inventory (BDI). The mean patient age was 59.9 +/- 14.1 (SD) years, 55% were Caucasian, 51% were male, and 39% had diabetes. The mean BDI score was 12.1 +/- 7.7; 49% had a score of 11 or greater. Fifty-five percent refused further assessment to confirm the diagnosis of major depression, while 45% of patients eligible for treatment agreed to further assessment. Their mean BDI was 18.8 +/- 6.2. Eighty-four percent were diagnosed with major depression on direct interviews and offered pharmacologic treatment, 16% did not meet the criteria for a diagnosis of depression, and 50% successfully completed 12 weeks of pharmacologic treatment. The BDI score of these patients at the start of treatment was 17.4 +/- 6.6, and at completion of treatment it was 8.4 +/- 3.0. Thirty-eight percent of treatment failures were in those who were also diagnosed with a DSM-IV personality disorder. Major depression is common in PD patients, and is potentially treatable with pharmacologic therapy. However, there are major problems providing a depression assessment and treatment program to such patients. Problems include refusal to complete depression assessment and patients with axis 2 personality disorders who have difficulty complying with treatment. Although depression treatment can improve depressive symptoms, it is unclear whether such therapy will improve medical outcomes.

In recent years, there has been an increased interest in performing hemodialysis (HD) more frequently than thrice weekly, particularly in the home setting. This interest has been stimulated by some studies that have indicated significant benefits to performing more frequent HD on various medical and quality of life outcome measures. However, only a few studies using varying quality of life instruments have critically examined the impact of frequent HD on the quality of life of patients. Although not consistent across studies, results suggest a positive impact of more frequent HD on patients' quality of life. It is hoped that the results of two landmark studies, now in progress (the Frequent Hemodialysis Network trial and the FREEDOM study), will provide more insight into the impact of more frequent HD on quality of life.

SUMMARY: Objective: C-reactive protein (CRP) levels increase during peritonitis. Little is known about the extent and duration of CRP elevation. Patients and Methods: Patients on continuous peritoneal dialysis (CPD) therapy had a baseline CRP value at the start of the study. CRP values were determined at 48 h, 2 weeks and 4 weeks after an episode of peritonitis developed in the 13 months after the study started. Results: The demographic values and comorbid diseases of the patients developing and not developing peritonitis were not significantly different. Patients who developed peritonitis had a mean ± SD CRP value of 15.0 ± 11.1 mg/L compared with 15.7 ± 9.9 mg/L in patients without peritonitis. The CRP value rose to 118.35 ± 96.86 mg/L at 48 h, and decreased to 34.5 ± 43.6 mg/L at 2 weeks and to 30.1 ± 39.7 mg/L at 4 weeks after the onset of peritonitis. All types of peritonitis were associated with a significant increase in CRP at 48 h. Nine patients had CRP elevations above baseline at 4 weeks; seven patients had active medical issues. Conclusion: CRP values become significantly elevated during peritonitis. Most patients have a decrease in the CRP values toward baseline values at 4 weeks following the onset of peritonitis while 20% of patients had continued elevations. The significance of the elevations is unclear. Given the associations of CRP with cardiovascular mortality in both uremic and non-uremic patients and the association of peritonitis with mortality, the role of this inflammatory marker deserves further evaluation.

Chronic kidney disease (CKD) is a significant public health problem: every year the number of Americans living with CKD and requiring renal replacement therapy increases. In addition, individuals with CKD have substantially increased morbidity and mortality compared to the general population. The Longitudinal Chronic Kidney Dialysis (LCKD) Study is a multicenter, prospective, observational study of patients with moderate to severe CKD that was designed to better describe the course of the disease and the determinants of patient outcomes. Patients with moderate to severe CKD (glomerular filtration rate [GFR] < 60 ml/min/m2) from four academic nephrology clinics were enrolled between 2000 and 2002. Special cardiac and vascular testing has recently commenced as phase II of this study. Areas that have been or are currently being studied include anemia management, health-related quality of life (HRQOL), medication use, and markers of cardiovascular disease. This article describes the LCKD Study in the context of current knowledge of CKD.

Depression has been documented as the most frequently encountered psychological problem in end-stage renal disease (ESRD) patients and has been correlated with both mortality and morbidity in these patients. Previous work by our group has shown that clinical depression is treatable with psychotropic medications in these patients, but that only a limited number of ESRD patients with depression will successfully complete a course of pharmacologic therapy. From July 1997 to October 2002, all chronic peritoneal dialysis (PD) patients in our facility were encouraged to be screened for depression utilizing the self-administered Beck Depression Inventory (BDI) questionnaire. Based on previous work, a score > or =11 on this questionnaire was used to indicate a possible diagnosis of clinical depression; patients with BDI scores > or =11 were encouraged to complete a more formal evaluation for the presence of clinical depression. A total of 320 BDI questionnaires were completed during the study period: 134 patients. (42%) scored > or =11 on the BDI, 69 of the 134 patients (51%) with BDI scores > or =11 agreed to further evaluation. Sixty of these 69 patients (87%) were diagnosed with clinical depression based on scores > or =18 on the Hamilton Depression Scale and standard Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. Forty-four patients with clinical depression agreed to pharmacologic treatment. However, only 23 of the 44 patients (52%) successfully completed a 12-week course of drug therapy. Two unit social work reviewers systematically reviewed the records of these 21 patients who did not complete therapy and assessed the reasons for their inability to complete treatment. Reasons identified included eight patients who experienced acute medical problems, three who were active substance abusers, and two who reported medication side effects. The remaining eight patients who did not complete the 12 weeks of therapy were examined by applying the axis 1 and axis 2 DSM-IV criteria. Axis 1 is used to diagnose clinical disorders and axis 2 is used to diagnose personality disorders. While all these patients met the DSM-IV axis 1 criteria for clinical depression, eight of these patients met axis 2 criteria for personality disorders; five patients had borderline personality disorders, one had a narcissistic personality disorder, one had a factitious disorder, and one had features of avoidant personality disorder. While some chronic PD patients can be successfully treated for clinical depression with psychotropic medication prescribed by the dialysis medical team, not all patients will agree to be evaluated for clinical depression and accept pharmacologic treatment. Others cannot or will not complete treatment when additional psychiatric disorders exist. These patients may require additional intervention when diagnosed with clinical depression and a personality disorder. Further trials are warranted.

The percentage of end-stage renal disease (ESRD) patients in the United States maintained on continuous peritoneal dialysis (CPD) therapy is decreasing. Complications from CPD therapy, including peritonitis, may be the reason for the decline. Improvements in CPD technology and a better understanding of the risk factors that predispose patients to the development of peritonitis have been responsible for a decline in the rate of peritonitis. Yet peritonitis remains a significant cause of patient morbidity and mortality and the overall outcome of peritonitis is not acceptable. Factors that have limited our ability to lessen the impact of peritonitis include a lack of data on dosing antibiotics in patients on continuous cycling peritoneal dialysis (CCPD) therapy, a lack of knowledge concerning the biology of bacterial biofilm, and the development of resistance to the current prophylactic antibiotic protocols. Further studies are needed concerning the optimal management of the peritoneal catheter and whether it is feasible to resume CPD therapy after catheter removal.

Few elderly patients with end-stage renal disease (ESRD) are treated with peritoneal dialysis (PD). Among dialysis patients >or=65 years of age reported by the U.S. Renal Data System (USRDS), the percentage treated with chronic peritoneal dialysis (CPD) is lower than in any other age group. To evaluate the effectiveness of automated peritoneal dialysis (APD) in the elderly, we compared several outcome measures in cohorts of different ages maintained on APD. The outcome measures we examined included mortality and technique failure rates, peritonitis rates, outcomes of peritonitis, and quality of life measures. We found that while patients >or=65 years of age have a higher mortality rate than younger patients, technique failure rates, overall peritonitis rates, and most quality of life measures are not different than for younger patients. However, patients >or=65 years of age have higher gram-negative peritonitis rates and lower scores on the physical component score of the SF-36 than younger patients. The present study suggests that APD is a reasonable treatment modality for elderly patients with ESRD and that elderly patients with progressive renal failure should be considered as candidates for APD.

Access-related infections are a leading cause of morbidity and mortality among hemodialysis patients. Staphylococcus aureus bacteremia accounts for 25% of these episodes. Nissenson et al., found that 20.7% of the patients developing S. aureus bacteremia had infectious complications as well as hospital readmissions related to the S. aureus bacteremia. This retrospective analysis did not determine whether the S. aureus bacteremia was access related, nor how each episode was treated. We have prospectively collected a database of all access-related S. aureus bacteremia developing in our unit between 1/1/03 and 8/31/05, including the management of the access. Episodes of S. aureus bacteremia with an identifiable source other than the vascular access were excluded. Seventy-two episodes of S. aureus bacteremia were identified; 54 developed in patients using a catheter and 18 developed in patients using an arteriovenous graft/fistula. The mean age was 64+/-15 years, and 56% of the patients were Caucasian. All patients were treated with 4 weeks of antibiotics. A total of 6 (8%) deaths and 15 (20.8%) infectious complications related to the S. aureus bacteremia were identified. Infectious complications included endocarditis (4), metastatic infection (7), discitis (3), and a myocardial abscess (1). Seventeen (23.6%) of the patients were readmitted within 30 days of the episode of S. aureus bacteremia; 4 readmissions were related to the S. aureus bacteremia. Five of the 54 catheter patients who developed S. aureus bacteremia expired and 14 developed infectious complications despite the catheter being removed/exchanged in all but one patient. One of the arteriovenous graft patients who developed S. aureus bacteremia expired. We conclude that infectious complications from S. aureus bacteremia are common, as 23.6% of the patients in our study developed an infectious complication. Eight percent of the patients who developed S. aureus bacteremia expired. Strategies to avoid S. aureus bacteremia are needed.

Bacteremia (B) is a well-known complication of an indwelling central venous catheter (CVC). Although prophylactic measures such as topical and catheter lock antibiotics have been demonstrated to decrease the risk of B in hemodialysis (HD) in patients with a CVC, there are concerns about the development of resistance to these agents when used for long periods of time. Objective: We wondered if we could limit the use of these agents by identifying the period when B was most common after CVC placement. Method: We prospectively noted all patients with a CVC who developed B in any of our 3 units in CT, U.S.A.; 62 episodes of B occurred between 1/1/03 and 9/18/03. 35% of all of the HD patients had a CVC for access during the study period. Results: Staphylococcus aureus accounted for 22 (35.5%) episodes; Gram-negative organisms for 21 (33.8%) and other staphylococcal species for 14 (22.6%). The other 3 episodes were other Gram-positive organisms and 6 patients developed B with more than 1 organism. 3 (4.8%) patients expired while being treated for the B. The average time to onset of B was 96 ± 98 CVC days with a range of 1–365 days. There was no difference in time to onset based on organism. 43.5% of the episodes of B occurred less than 60 days after the CVC was inserted, but 27.4% occurred greater than 100 days after CVC insertion. Conclusion: The time to onset of CVC-related B was variable among the patients developing B in this study. Preventative strategies aimed at reducing the risk of B in patients with a CVC must be used for the life of the CVC.

The Dialysis Outcome and Quality Initiative has guidelines for vascular access and states that the dialysis catheter (DC) should be limited to less than 20% of the end-stage renal disease (ESRD) patients. Our center has found this target difficult to achieve. Objective: We wondered what the reasons for use of a DC might be. Methods: We noted the number of patients with a DC in place and assessed the reasons why the DC was being used on 8/1/03. Results: 73 of the 170 (42.9%) patients had a DC on 8/1/03. 24 (32.9%) of the patients refused to have initial arteriovenous fistulae or grafts (AVF/G) or a secondary AVF/G revision or replacement procedure performed after initial AVF/G failure. 15 (20.5%) patients had a maturing AVF/G, 12 (16.4%) had significant medical and/or surgical contraindications for AVF/G placement, 9 (12.3%) patients were awaiting surgical thrombectomy, revision or placement of AVF/G, 6 patients (8.2%) were awaiting transfer to CPD therapy, 4 (5.5%) patients were undecided about having an AVF/G placed, and 1 (1.4%) had acute renal failure and early ESRD recovery was expected. Only 2 (2.7%) patients had no access plan by the nephrology team. Conclusions: Patients' refusal for an AVF/G placement and patients with a maturing AVF/G or awaiting surgical revision or placement were the most common reasons for the use of a DC in our center. To significantly impact on the high use of the DC, it would be crucial to better understand the reasons for patients’ refusals.