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Background: Hungry bone syndrome (HBS) is an important postoperative complication after parathyroidectomy for severe secondary hyperparathyroidism (SHPT). There is, however, little data in the literature on its detailed clinical course, and the associated risk factors remain controversial., Methods: We did a single-center retrospective study on 62 consecutive dialysis patients who underwent total parathyroidectomy for SHPT to examine the risk factors, clinical course and outcome. Data on demographic characteristics, perioperative laboratory parameters including serum calcium, phosphate, alkaline phosphatase (ALP) and parathyroid hormone (PTH), drug treatment for SHPT and operative details of parathyroidectomy were collected., Results: Seventeen (27.4%) patients developed severe postoperative hypocalcemia with HBS. The serum calcium dropped progressively while serum ALP rose after operation until 2 weeks later when serum calcium reached the trough and serum ALP peaked. Serum phosphate also fell but stabilized between 4 and 14 days. The total postoperative calcium and vitamin D supplementation was significantly larger, and hospital stay was significantly longer in the group with HBS as compared with those without HBS. Young age, high body weight, high preoperative ALP level, and low preoperative calcium level independently predicted the development of HBS while preoperative PTH and use of cinacalcet or paricalcitol did not., Conclusion: HBS was common after total parathyroidectomy in patients with SHPT, and it is important to closely monitor the postoperative serum calcium, phosphate and ALP levels in the following 2 weeks, especially for those at risk. The implications of our findings on perioperative management are discussed.

Background: The impact of a low-glucose peritoneal dialysis (PD) regimen on biomarkers of peritoneal inflammation, fibrosis and membrane integrity remains to be investigated., Methods: In a randomized, prospective study, 80 incident PD patients received either a low-glucose regimen comprising Physioneal (P), Extraneal (E) and Nutrineal (N) (Baxter Healthcare Corporation, Deerfield, IL, USA) (PEN group), or Dianeal (control group) for 12 months, after which both groups continued with Dianeal dialysis for 6 months. Serum and dialysate levels of vascular endothelial growth factor (VEGF), decorin, hepatocyte growth factor (HGF), interleukin-6 (IL-6), macrophage migration inhibitory factor (MIF), hyaluronan (HA), adiponectin, soluble-intracellular adhesion molecule (s-ICAM), vascular cell adhesion molecule-1 (VCAM-1) and P-selectin, and dialysate cancer antigen 125 (CA125), were measured after 12 and 18 months. This paper focuses on results after 12 months, when patients in the PEN group changed to glucose-based PD fluid (PDF)., Results: At the end of 12 months, effluent dialysate levels of CA125, decorin, HGF, IL-6, adiponectin and adhesion molecules were significantly higher in the PEN group compared to controls, but all decreased after patients switched to glucose-based PDF. Macrophage migration inhibitory factor level was lower in the PEN group but increased after changing to glucose-based PDF and was similar to controls at 18 months. Serum adiponectin level was higher in the PEN group at 12 months, but was similar in the 2 groups at 18 months. Body weight, residual renal function, ultrafiltration volume and total Kt/V did not differ between both groups. Dialysate-to-plasma creatinine ratio at 4 h was higher in the PEN group at 12 months and remained so after switching to glucose-based PDF., Conclusion: Changes in the biomarkers suggest that the PEN PD regimen may be associated with better preservation of peritoneal membrane integrity and reduced systemic vascular endothelial injury., (Copyright © 2015 International Society for Peritoneal Dialysis.)

Background: Encapsulating peritoneal sclerosis (EPS) is the most serious complication of peritoneal dialysis, having high morbidity and mortality. To improve outcomes, early diagnosis is needed to direct treatment during the early inflammatory phase. However, in the early inflammatory phase, clinical features are nonspecific, and no reliable diagnostic criteria have been established. Because bacterial peritonitis and termination of dialysis are two important risk factors triggering the progression of EPS, patients with refractory bacterial peritonitis necessitating dialysis catheter removal are at particularly high risk of developing EPS. Many of these patients might indeed experience non-resolving sterile peritonitis (probably the inflammatory phase of EPS) before progression to full-blown disease (that is, the presence of intestinal obstruction). We undertook a retrospective study to compare, in this particular situation, the clinical characteristics of patients with or without sterile peritoneal inflammation, assessing their clinical outcomes in terms of short-term mortality and the chance of developing full-blown EPS., Methods: Our retrospective review included 62 patients whose dialysis catheter was removed because of refractory peritonitis between January 2005 and December 2010., Results: Of the 62 patients identified, 39 (63%) had persistent sterile peritoneal inflammation ("high-risk" group, n = 39), and 23 (37%) had resolution of inflammation without significant intra-abdominal collection after catheter withdrawal ("control" group, n = 23). Compared with the control group, the high-risk group had a significantly longer PD duration (71.6 ± 43.3 months vs 42.3 ± 29.9 months, p = 0.003), a higher dialysate-to-plasma ratio (D/P) of creatinine (0.768 ± 0.141 vs 0.616 ± 0.091, p = 0.004), and a higher computed tomography score for EPS (7.69 ± 2.98 vs 1.00 ± 1.00, p < 0.001). During the 6-month study period, the high-risk group had a higher chance of developing full-blown EPS (31% vs 0%, p = 0.002) and a higher 6-month all-cause mortality (36% vs 4.3%, p = 0.004)., Conclusions: Persistent sterile peritoneal inflammation was common after dialysis catheter removal for refractory bacterial peritonitis, and the patients with such inflammation were at high risk of progression to full-blown EPS.

Objective: Fungal peritonitis (FP) is a serious complication of continuous ambulatory peritoneal dialysis (CAPD), being associated with significant morbidity and mortality. The role of nystatin prophylaxis during antibiotic therapy in the prevention of FP remains controversial, especially in programs with a modest or low baseline FP rate. The aim of the present study was to evaluate the effect of nystatin prophylaxis on the occurrence of FP in programs with a relatively modest baseline FP rate., Patients and Methods: Incident and prevalent patients receiving CAPD between April 1995 and April 2005 at our center were included and divided into 2 groups. The control group included 320 patients (total follow-up 8875 patient-months) being treated without nystatin before October 1999; the nystatin group included 481 patients (total follow-up 13725 patient-months) being treated after October 1999. Nystatin tablets (500,000 units, 4 times per day) were given orally during whatever use of antibiotics to cover the whole course of antibiotic therapy. Occurrence of FP and antibiotic-related FP (AR-FP) in patients with and without nystatin prophylaxis was compared., Results: The two groups were of similar age but the nystatin group had a significantly higher percentage of diabetics. In addition, the nystatin group had a higher proportion of patients using disconnecting twin-bag exchange systems and had a significantly lower peritonitis rate compared with the control. There were 13 and 14 episodes of FP in the nystatin and control groups respectively. The fungal peritonitis rate of the nystatin group was slightly lower than that of the control group (0.011 vs 0.019 per patient-year) but it did not reach statistical significance. There was, however, a significant decrease in the incidence and proportion of AR-FP in the nystatin group compared with the control group, which persisted even after adjustment for the peritonitis rate. Kaplan-Meier analysis further demonstrated significantly better AR-FP-free survival in the nystatin group compared with the control group. No significant side effects were observed for nystatin. Subgroup analyses in patients of the 2 different connecting systems revealed a similar but nonsignificant trend toward reduction of AR-FP in patients given nystatin prophylaxis., Conclusion: Oral nystatin prophylaxis might prevent the occurrence of AR-FP in CAPD patients, resulting in a trend toward reduction in the incidence of FP even in programs with a modest baseline FP rate. A large scale, prospective, randomized controlled trial is needed to further examine this issue.

Introduction: Hypertension is highly prevalent among continuous ambulatory peritoneal dialysis (CAPD) patients and is a major risk factor for cardiovascular complications. This study examines the risk factors associated with poorly-controlled hypertension in CAPD., Methods: We performed a cross-sectional study of 66 stable adult CAPD patients to evaluate their hypertension control over a period of three to four months and their associations with other clinical and laboratory parameters., Results: The mean age of the patients was 56.7 (plus or minus 1.27) years. Their mean systolic and diastolic blood pressure were 139 (plus or minus 2.59) mmHg and 77 (plus or minus 1.35) mmHg respectively; 71 percent of them were on antihypertensive drugs. Thirty (45.5 percent) patients had high blood pressure greater than 140/90mmHg. Compared with patients with normal blood pressure, patients with high blood pressure received significantly more antihypertensive drugs (p-value equals 0.034) and were more likely to be clinically overloaded (p-value less than 0.001). Multivariate analysis showed that systolic blood pressure was predicted by volume expansion (p-value less than 0.001) while diastolic blood pressure was negatively predicted by age (p-value equals to 0.004). In addition, volume overload was predicted positively by dialysate/plasma creatinine (p-value equals 0.011) and negatively by serum albumin (p-value less than 0.001)., Conclusion: Clinically-apparent volume overload was associated with poor systolic blood pressure control despite aggressive antihypertensive drug therapy. This finding underlines the importance of fluid control and could provide an explanation of the poor outcome observed in patients with high peritoneal transport.

Objectives: Factors that predict the occurrence of vascular events and poor patient survival in continuous ambulatory peritoneal dialysis (CAPD) patients have not been clearly defined. Previous studies have focused on nonselective CAPD patients, in whom pre-existing comorbidity or poor health might complicate interpretation of the significance of individual factors. The present study was conducted with CAPD patients without severe vascular and nutritional comorbidity., Patients and Methods: This single-center, prospective, observational study was conducted with 66 prevalent CAPD patients without co-existing severe vascular or nutritional problems. The patients were enrolled in January 1999. We monitored baseline demographic data and clinical and laboratory characteristics including average clinic blood pressure (BP), hemoglobin (Hb), serum albumin, intact parathyroid hormone (iPTH), serum cholesterol, triglycerides, dialysate-to-plasma (D/P) creatinine, dialysis adequacy [Kt/V and creatinine clearance (CCr)], and protein equivalent of nitrogen appearance. We followed the patients for 3 years. Outcome measures were actuarial patient survival, time to occurrence of cerebrovascular accident (CVA) and acute myocardial infarction (AMI), technique survival, and hospitalization rate., Results: Mean age of the patients was 56.7 +/- 10.3 years. Mean duration on CAPD at the time of enrollment was 36.4 +/- 21.7 months. Nineteen of the patients (28.8%) had diabetes. Most of the patients [n = 55 (83.3%)] were using three 2-L exchanges daily. Mean body weight was 56.3 +/- 12.2 kg. Mean total weekly Kt/V was 1.91 +/- 0.47, and mean total weekly CCr was 75.3 +/- 30.6 L/1.73 m(2). Actuarial patient survival was 96.9% at 1 year, 90.5% at 2 years, and 75.3% at 3 years. Overall technique survival was 96.9% at 1 year, 95.1% at 2 years, and 89.1% at 3 years. Multivariate analysis showed that age, diabetes mellitus (DM), and body size (weight or surface area) were independent predictors of patient survival. We estimated that a 1-kg increase in body weight was associated with a 6% increase in the relative risk of death (p = 0.015; 95% confidence interval: 1.013 to 1.126). Patients with a body weight of 60 kg or less showed a significantly better 3-year survival as compared with patients with body weight greater than 60 kg (88.1% vs 58.3%, p = 0.0042). No significant predictors were identified for technique failure or occurrence of a major vascular event. High BP and DM were independent predictors for hospitalization. Dialysis adequacy indices and serum albumin showed no significant effect on any outcome measure., Conclusions: Our study showed that, in addition to age and DM, body size could also be a significant factor affecting survival of CAPD patients. However, the underlying causative mechanisms remain unclear and require further study.

Objective: The efficacy of short-course triple eradication therapy has been documented in patients with Helicobacter pylori infection and normal renal function. We have evaluated a one-week proton-pump inhibitor-based triple therapy for Helicobacter pylori eradication in a retrospective review of patients with chronic renal failure., Methods: We studied 25 patients (mean age 65.1 +/- 2.4 years) with creatinine clearance <30 ml/min/1.73 m2 or serum creatinine level >200 micromol/L (13 on dialysis), who had Helicobacter pylori infection, documented by histological examination or rapid urease test, together with either peptic ulcer disease or severe gastritis. The combination of Omeprazole 20 mg BID or Lansoprazole 30 mg BID, amoxicillin 1 gm BID and clarithromycin 500 mg BID was given for one week, in addition to therapy for peptic ulcers. All patients were re-endoscoped four weeks later., Results: All but one patient (96%) had successful eradication. On repeat endoscopy, all 13 patients with peptic ulcers had healed ulcers. For the 12 gastritis patients, three became normal and nine had persistent gastritis. For patients not on dialysis, the serum creatinine level and creatinine clearance remained stable at two weeks after treatment (303 +/- 37 vs. 330 +/- 36 micromol/l, p=ns; 23.6 +/- 3.4 vs. 26.0 +/- 3.9 ml/min/1.73 m2, p=ns, respectively)., Conclusion: The short course triple therapy was highly efficacious for Helicobacter pylori eradication in patients with chronic renal failure, with no adverse effect on renal function.

Background: The efficacy of short-course triple therapy for the eradication of Helicobacter pylori has been documented in patients with normal renal function. We evaluated the efficacy and safety of a 1-week proton-pump inhibitor-based triple therapy for H pylori eradication in a prospective study of patients with chronic renal failure (CRF)., Methods: Forty-two patients with a creatinine clearance (CrCl) less than 30 mL/min/1.73 m2 or serum creatinine level greater than 2.26 mg/dL (>200 micromol/L; n = 21; CRF group; 12 patients on dialysis therapy) or normal renal function (n = 21; controls) were studied when they had H pylori infection on top of peptic ulcer disease (20 patients) or gastritis (22 patients). The combination of omeprazole, 20 mg twice daily; amoxicillin, 1 g twice daily; and clarithromycin, 500 mg twice daily, was administered for 1 week. All patients underwent repeated endoscopy 4 weeks later for assessment of eradication. Apart from patients on dialysis therapy, all patients had serum creatinine levels and CrCls measured 2 and 4 weeks after treatment., Results: All except 5 patients (2 patients, CRF group; 3 controls) had successful eradication (90.5% versus 85.7%). For patients not on dialysis therapy, serum creatinine levels and CrCls remained stable 4 weeks after treatment (serum creatinine, 3.68 +/- 1.09 versus 3.76 +/- 1.09 mg/dL [325 +/- 96 versus 332 +/- 96 micromol/L]; P = not significant [NS]; CrCl, 21.4 +/- 8.3 versus 22.2 +/- 6.9 mL/min/1.73 m2; P = NS)., Conclusion: The 1-week course of proton-pump inhibitor-based triple therapy achieved a high eradication rate of H pylori infection in patients with CRF, similar to controls with normal renal function. The regimen was well tolerated., (Copyright 2002 by the National Kidney Foundation, Inc.)