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Encapsulating peritoneal sclerosis is a rare but devastating complication of long-term peritoneal dialysis with a high mortality rate. The incidence is between 0.5 and 2.5%, decreasing with time. PSE is defined as a clinical syndrome with signs of gastrointestinal obstruction, inflammation parameters, radiological and macroscopic changes. The duration of treatment and the cessation of peritoneal dialysis are the main risks. About 75% occured in patients on hemodialysis or after kidney transplantation. Morphological alterations are disappearance of mesothelial layer, submesothelial fibrosis, interstitial sclerosis and vasculopathy. Ultrafiltration failure, fast transport status of the peritoneal membrane and loss of sodium sieving, the most powerful predictor, are the functional abnormalities. Biomarkers in peritoneal effluent include cancer antigen 125, interleukin-6. The pathophysiology is probably a consequence of a multiple-hit process in which expression of growth factors and cytokines play a central role. Medical strategies (corticosteroids, tamoxifen) in association with parenteral nutrition and/or surgery (enterolysis) are discussed. Prevention is the use of physiological peritoneal dialysis solutions, icodextrine instead of high glucose concentration solutions and peritoneal lavage after peritoneal dialysis stopping.

There are evidences supporting a positive impact of renal residual function (RRF) on survival and quality of life of dialysis patients. Many strategies are available in clinical practices to maintain RRF. Hemodiafiltration seems to be better that conventional hemodialysis and similar to peritoneal dialysis. Arterial hypotension in hemodialysis or dehydration in peritoneal dialysis are deleterious in terms of preservation of RRF. Loop diuretics increase urine volume and natriuresis, not RRF. Radiocontrast and aminoglycosides may be used safely. The benefits of ACE inhibitors and angiotensin II receptor blockers are debated but have positive effect on blood pressure control and cardiac function. Neither biocompatible solutions nor the modality of peritoneal dialysis have demonstrated benefits on RRF.

The optimal method to assess the adequacy of peritoneal dialysis therapies is controversial. Today, the adequacy must not be considered as a number or a concept assessed only by two parameters (total KT/V urea and total solute clearance) but defined by many more items. In the absence of data, based on theoretical considerations, the reanalysis of the CANUSA study showed that renal kidney function, rather than peritoneal clearance, was associated with improved survival. Residual renal function is considered as a major predictor factor of cardiovascular mortality. Results of this reanalysis were supported by the adequacy data in ADEMEX, EAPOS and ANZDATA studies. Therefore, clinical assessment plays a major role in PD adequacy. The management of fluid balance, the regular monitoring of malnutrition, the control of mineral metabolism and particularly the glucose load, considered as the "corner-stone" of the system, are the main points to be considered in the adequacy of PD patients. The essential goal is to minimize glucose load by glucose-sparing strategies in order to reduce the neoangiogenesis of the peritoneal membrane.

Background Technical failure is more likely to occur in the first 6 months of peritoneal dialysis (PD). This study was carried out to identify risk factors for early transfer from PD to haemodialysis (HD) in a country where assisted PD is available. Methods All patients from the French Language Peritoneal Dialysis Registry (RDPLF) who started PD between 1 January 2002 and 31 December 2010 were included. Time to transfer, death and transplantation during the first 6 months on PD were analysed by the multivariate Cox proportional hazard model. The Fine and Gray model was used to examine the occurrence of technical failure by considering death and transplantation as competing events. Results Of 9675 patients included, 615 (6.3%) moved to HD during the first 6 months of PD. Cumulative incidence of transfer to HD was 6.6% at 6 months. On multivariate analysis by both the Cox model and the Fine and Gray model, HD prior to PD, allograft failure and early peritonitis were associated with a higher risk of early technical failure, whereas being dialysed in a centre treating more than 20 new patients per year was associated with a lower risk of early transfer to HD. Conclusions Patients treated by HD before PD and failed transplant patients had a higher risk of early PD failure when competing events were considered.

Gueutin V, Ficheux M, Châtelet V, Lecouf A, Henri P, Hurault de Ligny B, Ryckelynck J-P, Lobbedez T. Hydration status of patients with end-stage renal disease after kidney transplantation. Clin Transplant 2011: 25: E656–E663. © 2011 John Wiley & Sons A/S. Abstract: Background: This study was carried out to estimate the modification of hydration status within the first three months of renal transplantation. Subjects and methods: Fifty patients who underwent a first kidney allograft were prospectively followed for three months after renal transplantation to assess hydration status by bioimpedance spectroscopy. Results: Two hours before the transplant procedure, 10/42 (23.8%) patients were overhydrated. Two days after surgery, 32/40 (80.0%) patients were overhydrated and at three months, 14/27 (51.9%) patients remained fluid-overloaded. Peritoneal dialysis (PD) patients had a lower hydration status (−0.60 L) than hemodialysis (HD) patients (0.70 L; p

Post-transplant diabetes mellitus (PTDM) is a well-known complication in renal transplant recipients (RTRs). While a number of risk factors for PTDM have been identified, the potential impact of pre-transplant dialysis modality on subsequent development of PTDM has not yet been explored. We performed a multicenter retrospective study on 2010 consecutive RTRs who did not have a history of diabetes prior to renal transplantation. PTDM was defined as a need for anti-diabetic therapy in an RTR without a history of diabetes prior to transplantation. Analysis of the risk factors for development of PTDM was performed with respect to pre-transplant dialysis modality. A total of 137 (6.8%) patients developed PTDM; 7% in the hemodialysis group and 6.5% in the peritoneal dialysis (PD) group (p = 0.85). In the multivariate analysis, age (p

Lymphocele is a common surgical complication after renal transplantation. The incidence of lymphocele ranges from 0.6% to 18%. The aim of this study was to determine incidence, risk factors and prognosis of complicated lymphocele in the era of modern immunosuppression. We retrospectively reviewed 311 renal transplants from January 2003 to September 2008, we excluding patients who received sirolimus or underwent multiorgan transplantations. A complicated lymphocele was defined by the requirement for a surgical procedure for cure. Of the 311 transplant recipients, we included 269 in the study with 49 (18.9%) presenting a complicated lymphocele after transplantation. Cold ischemia time, waiting time on dialysis, gender, donor source, induction therapy (thymoglobulin vs basiliximab), and dialysis modality were similar between the 2 groups. Mycophenolate mofetil (MMF) doses were higher among the lymphocele than the nonlymphocele group (2.7 ± 0.54 g/d vs 2.36 ± 0.68 g/d; P < .05). However, the areas under the concentration-time curves of mycophenolic acid were not significantly different between the 2 groups (43.7 ± 15.3 h·mg/L vs 48 ± 21 h·mg/L; P = .33). However, a multivariate analysis showed complicated lymphocele to be associated with greater MMF doses (odds ratio [OR] 2.75; P < .01), warm ischemia time (OR 1.035; P < .05), and recipient age (OR 1.04; P < .05). In conclusion, we identified high MMF doses as an independent risk factor for lymphocele formation after renal transplantation.

The frequency of transfers from peritoneal dialysis to haemodialysis secondary to the catheter-related complications has been estimated between eight to 20% depending the countries. Therefore, it is recommended that the insertion of peritoneal dialysis catheters be made by competent and experienced operators. Indeed, despite the development of new insertion techniques and the availability of new sophisticated catheters, the major prognostic factor remains the quality of the surgical procedure and the postoperative care. As regards the choice between various catheters, there is no consensus for the superiority of one in comparison with others. However it should be noted that a catheter survival rate from 80 to 90% at one year is a recognized index of quality.

Background: C.E.R.A., a continuous erythropoietin receptor activator, is in development to provide anemia correction and stable maintenance of hemoglobin (Hb) levels at extended administration intervals in patients with chronic kidney disease (CKD). This study examined its efficacy and safety when administered up to once monthly in patients who have CKD and are on dialysis and randomly convert directly from epoetin α or β one to three times weekly. Design, setting, participants, and measurements: In this three-arm, comparator-controlled, open-label, randomized, parallel-group, Phase III study, 572 dialysis patients (≥18 yr) who were receiving stable subcutaneous epoetin one to three times weekly were randomly assigned (1:1:1) to continue epoetin or to receive subcutaneous C.E.R.A. once monthly or twice monthly for 52 wk. Dosage was adjusted to maintain Hb ±1.0 g/dl of baseline level. Primary end point was mean change in Hb level between baseline and the evaluation period (weeks 29 to 36). Results: Mean Hb levels during the evaluation period were similar between groups (once-monthly C.E.R.A. 11.5 g/dl; twice-monthly C.E.R.A. 11.7 g/dl; epoetin 11.5 g/dl). The difference between C.E.R.A. and epoetin in mean change (97.5% confidence interval) in Hb concentration between baseline and evaluation was −0.022 g/dl (−0.262 to 0.217) for once monthly and 0.141 g/dl (−0.098 to 0.380) for twice monthly. Analysis demonstrated that C.E.R.A. was as effective as epoetin in maintaining Hb and was well tolerated. Conclusions: Subcutaneous C.E.R.A. once or twice monthly successfully maintained tight and stable Hb levels in patients who were on dialysis and randomly converted directly from epoetin one to three times weekly.

The Registre de Dialyse Péritonéale de Langue Française (RDPLF Registry) is a non-profit association that has been set up to assist physicians and nurses in evaluating their practical experience and results regarding peritoneal dialysis (PD). Five French-speaking and two Spanish-speaking countries have participated in this initiative (which includes 21 000 patients). In France, 82% of all PD patients are included in the registry and the main results for the period from 1995 to January 2006 form the basis of this report: of 11 744 incident patients with a median age of 71 years, 21.5% were over 80 years of age and 56% were not able to perform PD treatment at home without assistance. Eighty-six percent of the latter group received external assistance from a private nurse and 14% were aided by their family. The overall average rate of peritonitis was one episode every 29 months. The probability of being peritonitis-free appeared to be better for patients on automated PD (59.4% at 2 year) than for those on continuous ambulatory PD (55.3%), but this finding requires further validation. The average waiting time before transplantation was about 2 years. In patients who had undergone transplantation, the peritonitis rate was one episode per 42 months before transplantation compared to one episode per 29 months for patients who had not received a transplant. Eighty-three percent of patients had a hemoglobin level greater than 11 g%. Catheter survival was 92% at 2 years post-insertion and 85% at 5 years, with 94% being implanted by experienced surgeons. In conclusion, the RDPLF results demonstrate that PD may be successfully prescribed for older patients who receive assistance either from their family or from a nurse. Further, a larger number of younger patients should also be prescribed this technique in France. Patients eligible for transplantation and on short-term PD have the lowest risk of developing peritonitis; PD before transplantation may help prolong residual renal function, and initial treatment by PD may also help to preserve vascular access for the future.

Peritonitis is still a frequent complication in peritoneal dialysis patients. Medical guidelines have been established to manage this infection. These guidelines do not provide any information regarding the requirement for hospitalization. The main objective of this study was to evaluate the impact of peritonitis episode on the hospitalization rate and on the hospitalization duration in a centre where peritoneal dialysis patients were hospitalized in case of peritonitis. This was a retrospective study of incident peritoneal patients over a six years period. Among 101 peritoneal dialysis patients 65% were hospitalized. Two hundred and twenty hospital stays were registered. The total duration of hospital stays was 2091 days. The hospitalization rate was 2 per patient and per year, the hospital duration was 19 days per patient per year. Of the 220 hospital stays, 67 (30%) were due to a peritoneal infection. Peritonitis episodes represent 581/2091 (28%) days of hospitalization. The mean duration of hospitalization for peritonitis was 8.7+/-7 days. Among the patients hospitalized for a peritonitis episode, 57% were assisted by a nurse at home to perform their peritoneal dialysis exchanges. Of the 67 peritonitis episodes, 91% were discharged from the hospital without any complication. This study emphases the fact that peritonitis has an important impact on the hospitalization rate and on the hospitalization duration in peritoneal dialysis patients. In an attempt to decrease the rate of hospitalization, educational programs are clearly needed in order to treat more peritonitis without any hospitalization requirement.

Access to, and outcome of, renal transplantation according to treatment modality of end-stage renal disease in France.BackgroundAlthough peritoneal dialysis (PD) is recognized as one of the methods of treatment of end-stage renal disease (ESRD), there have been recurrent concerns about the access of patients treated by this modality to kidney transplantation (KTx), as well as reports showing increased complications of KTx in such patients, such as graft thrombosis and infections.MethodsThe aim of this study was to provide a comprehensive view of the impact on transplantation of pretransplant modality of treatment of ESRD using a multivariate analysis of the French database. From 1997 to 2000, after exclusion of pediatric patients, multiple transplantations, and living donors, 6420 were patients registered on the waiting list, and 3464 were transplanted.ResultsUsing a Cox proportional hazard analysis, we found a shorter waiting time for PD patients (RR 0.71, P < 0.0001), which became equivalent to hemodialysis (HD) patients when taking into account the transplant center as a variable (RR 1.0, P = 0.95). Concerning graft survival, only preemptive transplantation had a significant impact, being associated to a decreased risk of graft failure (RR 0.46, P = 0.005).ConclusionOur study supports the concept that the choice of any pretransplant dialysis modality does not influence waiting time for transplant or the results of transplantation.

Peritoneal dialysis patients are frequently transferred from peritoneal dialysis to haemodialysis. In contrary transfer from chronic haemodialysis to peritoneal dialysis is rare. The aim of this study is to describe the main characteristics and the outcome of the dialysis patients transferred from haemodialysis to peritoneal dialysis. We retrospectively analyzed the files of 25 patients treated by haemodialysis for more than 3 months between 1992 and 2002 and subsequently transferred on peritoneal dialysis. Technique survival was 56% at 1 year and 40% at two years in haemodialysis. Technique survival was lower in the group starting haemodialysis in emergency compared with the group of patients who did not need emergent haemodialysis (33 vs 77% at 1 year, P

BACKGROUND The theoretical aim of maintenance cyclosporine monotherapy (mCsA) after kidney transplantation is to reduce the incidence of the metabolic complications of corticosteroids and to minimize the adverse effects of excessive long-term immunosuppression. This study was performed in low-immunological-risk cadaveric kidney transplant recipients to evaluate the risks and benefits of mCsA and the long-term graft survival, and to determine the factors predicting success of this policy. METHODS The multicenter retrospective study was conducted in 329 Caucasian patients receiving mCsA out of 728 first cadaveric kidney transplant recipients. The inclusion criteria were: HLA antibodies < or =25%, serum creatinine

Introduction Mycophenolic acid (MPA) pharmacokinetics exhibit large variability in transplant recipients and may be altered due to concurrent immunosuppressants. Little is known about the influence of sirolimus (SRL) on MPA pharmacokinetics in kidney transplant patients. Methods We studied the areas under concentration-time curves (AUC) for MPA in 15 patients receiving immunosuppression combining SRL with mycophenolate mofetil (MMF). The pharmacokinetic measurements were performed in all patients using three MMF dosing regimens (0.5 g twice a day, 0.75 g twice a day, 1 g twice a day). Similar blood AUC profiles were also sampled from 12 patients treated with a fixed dose of MMF 1 g twice a day and cyclosporine (CsA). MPA was measured using HPLC; the AUC0–12 of MPA was determined by the trapezoidal method using four sampling time points: C0, C1, C3, C5. Results While patients on SRL were receiving 0.75 g MMF twice a day, mean AUC0–12 and C0 values of MPA were comparable to those of patients receiving CsA and 1 g MMF twice a day (54.1 ± 17.6 and 3 ± 1.87 vs 51.7 ± 16.7 mg · h/L and 2.76 ± 1.57 mg/L, respectively). On the other hand, 0.5 g MMF twice a day with SRL therapy resulted in AUC0–12 and C0 values of MPA of 32.3 ± 12.6 mg · h/L and 2.32 ± 1.72 mg/L, respectively, whereas, 1 g MMF twice a day with SRL resulted in AUC0–12 and C0 values of MPA of 70.9 ± 19.3 mg · h/L and 4.7 ± 2.44 mg/L, respectively. Conclusions These findings demonstrate that MPA exposure in the presence of SRL is higher than that with CsA. It appears that the MMF dose should be reduced to 0.75 g twice a day in patients receiving SRL to obtain AUC0–12 of MPA levels comparable to that in patients treated with CsA and MMF 1 g twice a day.

Background. This study was carried out to examine the association of sub-optimal dialysis initiation of peritoneal dialysis (PD) with all the possible outcomes on PD using survival analysis in the presence of competing risks. Methods. This was a retrospective cohort study based on the data of the French Language Peritoneal Dialysis Registry. We analysed 8527 incident patients starting PD between January 2002 and December 2010. The end of the observation period was 01 June 2011. Times from the start of PD to death, transplantation, transfer to haemodialysis (HD) and first peritonitis episode were calculated. The sub-optimal dialysis initiation was defined by a period of

Summary Background and objectives This study assessed whether assisted peritoneal dialysis (PD) was associated with a lower risk for technique failure using methods developed for survival analysis in the presence of competing risks. Design, setting, participants, & measurements This retrospective cohort study, based on data from the French Language Peritoneal Dialysis Registry, analyzed 9822 incident patients starting PD between January 2002 and December 2010. The observation period ended on June 1, 2011. Time to transfer to hemodialysis was compared between patients with assisted PD and those undergoing self-care PD. Results There were 5286 patients undergoing assisted PD; 4230 of these were assisted by a community nurse and 1056 by family. Assisted PD patients were older and had a higher Charlson comorbidity index than self-care PD patients. There were 7594 events: 3495 deaths, 2464 transfers to hemodialysis, 1489 renal transplantations, and 146 renal function recoveries. According to a Cox model, assistance and center size were associated with a lower risk for technique failure, whereas hemodialysis before PD, early peritonitis, and transplantation failure were associated with a higher risk for transfer to hemodialysis. A Fine and Gray regression model showed that assisted PD was associated with a lower risk for transfer to hemodialysis. Conclusions Compared with patients undergoing self-care PD, those with assisted PD had a lower risk for transfer to hemodialysis, a higher risk for death, and a lower risk for transplantation.

It is well established that technique failure is one of the main reasons for peritoneal dialysis cessation. Early PD failures occur during the first 6 months of PD and are mainly related to catheter dysfunction and psychosocial problems. Catheter malfunction should be treated by a video-laparoscopic procedure as this prolongs the catheter survival. Assisted peritoneal dialysis could help patients to cope with peritoneal dialysis. Preservation of residual renal function is of importance in peritoneal dialysis patients as it affects both patients and technique survival. Failure to obtain a sufficient ultrafiltration volume to maintain a euvolemic state without using large amount of hypertonic glucose solution can cause peritoneal dialysis failure. New approaches in the use of icodextrin to increase ultrafiltration and sodium removal are under investigation. A novel modality of prescribing automated peritoneal dialysis would improve ultrafiltration in peritoneal dialysis patients.

Background. The number of elderly patients starting dialysis is increasing in developed countries. Older age is frequently associated with contraindication of peritoneal dialysis (PD). The aim of this study was to report the outcome of elderly patients on PD in a country where assisted PD is available. Methods. This was a retrospective study based on the data of the French Language Peritoneal Dialysis Registry (RDPLF). We retrospectively analysed 1613 patients older than 75 years who started PD between January 2000 and December 2005. The end of the observation period was 31 December 2007. Results. The mean age at dialysis initiation was 81.9 years; 545 patients had a Charlson comorbidity index (CCI) >9. Of these 1613 patients, 1435 were treated by continuous ambulatory peritoneal dialysis (CAPD) and 1232 were on assisted PD. The median patient survival was 27.1 months. In the multivariate analysis, patient survival was associated with sex, age, modified CCI, method of assistance and underlying nephropathy. The median pure technique survival was 21.4 months. In the Cox model, technique survival was associated with the modified CCI, but the association did not remain significant after adjustment for the centre size. The median survival free of peritonitis was 32.1 months. Neither the modality of assistance nor the centre size was associated with peritonitis risk. Conclusion. PD is a suitable method for elderly patients. In order to increase the rate of PD utilization in elderly patients, the need for the funding of assisted peritoneal dialysis has to be taken into account.

Peritoneal dialysis is commonly used in patients awaiting renal transplantation. The occurrence of delayed graft function is lower in CAPD patients than in hemodialysis patients. This could be explain

Starting dialysis in an unplanned manner is a frequent situation in a dialysis centre even for patients with a regular nephrology follow-up. For no clear reason, chronic haemodialysis (HD) is more frequently used than peritoneal dialysis for unplanned dialysis patients.The purpose of this study was to evaluate the results of a dialysis policy dedicated to unplanned dialysis patients. The aim of this policy was to increase the use of peritoneal dialysis (PD) in an attempt to reduce the need for tunnelled catheter.One hundred seventy-one patients from a single centre, who started dialysis between 1 January 2004 and 31 December 2006, were prospectively followed until 31 December 2006. Unplanned dialysis patients were defined as patients entering in dialysis with no vascular access or peritoneal dialysis catheter. PD was presented as a modality of choice for renal replacement therapy to avoid the need for a tunnelled HD catheter.There were 60 unplanned dialysis patients during the study period. Among these patients, 34 agreed to be treated by PD. Compared with unplanned peritoneal dialysis patients, unplanned haemodialysis patients had a greater modified Charlson's comorbidity index (5.9 +/- 2.4 versus 4.4 +/- 1.9, P0.05). The mean duration of the temporary catheter period was 32 +/- 29 days (median: 24 days) for haemodialysis patients compared with 26 +/- 21 days (median: 25 days) for peritoneal dialysis patients (P = NS). The initial hospitalization duration was similar in haemodialysis patients and peritoneal dialysis patients (24 +/- 28 versus 30 +/- 33 days; median value: 17 versus 20 days, P = NS). PD was started 8.6 +/- 10 days (median: 4 days) after catheter insertion. A tunnelled catheter was used only in three patients until peritoneal dialysis was initiated. Acute automated peritoneal dialysis was used in 19 patients. Among 26 haemodialysis patients, 23 were dialyzed through a tunnelled catheter. Of these 23 patients, 15 were successfully converted to fistula. Median time for fistula creation was 2.6 months after dialysis initiation; median time for fistula utilization was 4.4 months. Actuarial patients survival at 1 year was 79% on haemodialysis compared with 83% on peritoneal dialysis (P = NS). After adjustment of the initial modified Charlson's comorbidity index, dialysis modality had no impact on patient's survival. There was no significant difference between haemodialysis patients and peritoneal dialysis patients regarding survival free of re-hospitalization. Actuarial survival free of peritonitis was 73% at 6 months and 58% at 1 year.Peritoneal dialysis is a safe and efficient alternative to haemodialysis for unplanned dialysis patients. Peritoneal dialysis offers the advantage of reducing the need for tunnelled catheter in unplanned dialysis patients.

Previous series have reported weight gain after kidney transplantation. However few studies have investigated the body composition after kidney transplantation, particularly during longitudinal follow-up. In this prospective study, we assessed the changes in body composition after kidney transplantation. We also analyzed the effect of steroid withdrawal from the immunosuppressive regimen on weight gain and body composition. Methods. Thirty-eight cadaveric kidney transplant recipients were followed for 2 years posttransplant. Total and segmental body composition were measured by dual energy X-ray absorptiometry (DEXA) at the time of transplantation as well as 3, 6, 12, and 24 months later. Results. In 28 patients (group A), prednisone was stopped by month 6, whereas, in 10 patients (group B), it was continued throughout the study. In the overall patient group, there were no significant changes in body weight. However, a trend to increased weight was observed in group B. In this group, patients showed an early increase in total body fat with a central accumulation of fat mass that was maintained during the follow-up period. On the other hand, total lean mass increased significantly in group A but did not change significantly in group B. Conclusion. In summary, overall the group showed no major changes in body weight during the 2 years after transplantation. Steroid withdrawal in kidney transplant recipients may have a significant positive effect on body composition.

Early loss of renal grafts is generally caused by vascular or immunologic complications. We describe two patients who received a kidney transplant from the same donor and lost their grafts during the first posttransplant week. Both cases presented necrotizing graft vasculopathy without inflammatory element. The donor was a 21-year-old woman who regularly used "ecstasy" over a 2-year period. After an extensive work-up to investigate the potential causes of graft loss, we considered the possibility of ecstasy being the cause of these two renal-graft losses.

HUMAN CYTOMEGALOVIRUS (HCMV) infection is a frequent complication of renal transplantation. Treatment should start early in the course of the viral infection to obtain the best results. HCMV must be detected before clinical symptom appearance, but virus detection is not always followed by HCMV disease. Therefore, treatment is not necessary every time HCMV infection is detected in a patient. For this reason, it is very important to have an early diagnostic system to obtain a correlation between the results and the disease gravity. The objective of this study is to compare four HCMV diagnostic methods: DNA in sera by polymerase chain reaction (PCR), DNA in leukocytes by PCR, pp65 leukocytic antigenemia, and viremia to predict symptomatic HCMV infection.

The pharmacokinetics of fluconazole given orally (100 mg) or intraperitoneally (50 and 150 mg) were determined in 15 patients with chronic renal failure who were undergoing continuous ambulatory peritoneal dialysis. The half-life (72 to 85 hours) was intermediate between values obtained in healthy volunteers and in patients with renal insufficiency studied during an interhaemodialysis period. The peritoneal clearance, 0.26 to 0.33 L/h, led to an 18% recovery of administered drug in the dialysates after 48 hours. The peritoneal absorption was slow (time to peak plasma concentration 7 hours) but the peritoneal bioavailability was excellent at 87 +/- 5%. The mean concentrations of fluconazole up to 24 hours were 770 and 1900 micrograms/L after single intraperitoneal doses of 50 and 150 mg, respectively. The volume of distribution (40 to 60 L) did not differ from that determined in patients with normal renal function. In the case of fungal peritonitis essentially attributed to Candida spp., a 6-hour intraperitoneal infusion of fluconazole 150 mg every 2 days appears to be a good regimen to rapidly exceed minimum inhibitory concentrations and treat infection without risk of systemic dissemination of fungi or toxicity.

In France, the use of peritoneal dialysis (PD) as the first-choice treatment varies greatly between districts, as it is already known to do between countries. Baseline clinical factors associated with choice of first modality were analyzed in 10815 new end-stage renal disease patients in 59 districts. To describe practices at the district level, we used an agglomerative hierarchical classification, with proximity defined by a likelihood-ratio test that compared multivariate logistic regressions of the following factors: age, gender, diabetes, congestive heart failure, severe behavioral disorders, mobility, and employment. To propose a typology, each cluster of districts was described by a multivariate logistic regression. While populations starting PD in France, as elsewhere, are more likely to be young or employed, they are also more likely to be elderly or have congestive heart failure or severe behavioral disorders. Overall, 14% of patients start with PD, but this rate varies significantly across districts, from 0% to 45%. A specific combination of factors was associated with the first-choice modality in each group of districts. This study highlights the lack of consensual medical criteria for this choice and the likelihood that nonmedical factors may explain the observed differences. The high variability suggests that PD can be used in almost all clinical conditions. Accordingly, patient preference should play a more important role in the decision-making process.