Polydipsia : a feature of peritoneal dialysis

Background Some dialysis patients fail to comply with their fluid restriction causing problems due to volume overload. These patients sometimes blame excessive thirst. There has been little work in this area and no work documenting polydipsia among peritoneal dialysis (PD) patients. Methods We measured motivation to drink and fluid consumption in 46 haemodialysis patients (HD), 39 PD patients and 42 healthy controls (HC) using a modified palmtop computer to collect visual analogue scores at hourly intervals. Results Mean thirst scores were markedly depressed on the dialysis day (day 1) for HD (P<0.0001). The profile for day 2 was similar to that of HC. PD generated consistently higher scores than HD day 1 and HC (P = 0.01 vs. HC and P<0.0001 vs HD day 1). Reported mean daily water consumption was similar for HD and PD with both significantly less than HC (P<0.001 for both). However, measured fluid losses were similar for PD and HC whilst HD were lower (P<0.001 for both) suggesting that the PD group may have underestimated their fluid intake. Conclusion Our results indicate that HD causes a protracted period of reduced thirst but that the population's thirst perception is similar to HC on the interdialytic day despite a reduced fluid intake. In contrast, the PD group recorded high thirst scores throughout the day and were apparently less compliant with their fluid restriction. This is potentially important because the volume status of PD patients influences their survival.

Vitamin D intake, sun exposure and 25-hydroxy vitamin D status in Peritoneal dialysis (PD) and Haemodialysis (HD) patients

Inadequate vitamin D levels have been linked to bone disease but more recently have been associated with wider health implications. Limited studies suggest a high prevalence of Vitamin D deficiency in dialysis patients, although evidence is lacking on whether this is due to dietary restrictions, limited mobility and time outdoors or a combination of these. The aim of this study was to assess the contributions of diet, supplements and sunlight exposure to serum Vitamin D (25(OH)D) levels in dialysis patients. Cross-sectional data were obtained from 30 PD (Mean±SD age 56.9±16.2 y; n=13 male) and 22 HD (Mean±SD age 65.4±14.0 y; n=18 male) patients between 2009 and 2010. Serum 25(OH)D was measured and oral vitamin D intake estimated through a food-frequency-questionnaire and quantifying inactive supplementation. Sunlight exposure was assessed using a validated questionnaire. Prevalence of inadequate/insufficient vitamin D differed between dialysis modality (31% and 43% insufficient (<50nmol/L); 4% and 34% deficient (<25nmol/L) in HD and PD patients respectively (p=0.002)). In HD patients, there was a significant correlation between diet plus supplemental vitamin D intake and 25(OH)D (ρ=0.84, p<0.001). Results suggest a higher frequency of 25(OH)D inadequacy/deficiency in PD compared to HD patients. No other relationships between intake, sun exposure and 25(OH)D were seen. This could reflect limitations of the study design or the importance of other factors such as age, ethnicity and sun protection as interactions in the analysis. Understanding these factors is important given Vitamin D’s emerging status as a biomarker of systemic ill health.

A clinical audit to compare peritonitis rates between peritoneal dialysis delivery systems

Peritonitis is a major problem for patients with end-stage kidney disease undergoing peritoneal dialysis (PD). It is the main cause of failure of PD. Two different PD delivery systems are used across Australia although there is inconsistent evidence comparing the systems. The aim of this retrospective audit is to compare the rates and risk of peritonitis in a cohort of incident patients using two PD delivery systems. All consecutive patients starting PD between 1 August 2010 and 31 March 2012 were included and followed until 30 June 2013. Data relating to accepted risk factors for peritonitis were collected and analysed. There were 50 patients (26 men; 24 women) aged between 30 and 87 years. There were 29 episodes of peritonitis in 17 patients. Rates of peritonitis were 1 episode per 69.19 patient-months compared with 1 episode per 18.67 patient-months. Mean times to first episode of peritonitis were 13.11 months compared to 7.13 months. The relative risk of PD-related peritonitis was twice as high (RR = 2.04, 95% CI = 0.85 to 4.94) for patients using the one system (44.4%) compared to a second system (21.7%). Since this is not a randomised trial no firm conclusions can be drawn. Centres should also monitor peritonitis rates for each system.

Compliance in peritoneal dialysis : a qualitative study of renal nurses

End-stage renal failure is a life-threatening condition, often treated with home-based peritoneal dialysis (PD). PD is a demanding regimen, and the patients who practise it must make numerous lifestyle changes and learn complicated biomedical techniques. In our experience, the renal nurses who provide mostPDeducation frequently express concerns that patient compliance with their teaching is poor. These concerns are mirrored in the renal literature. It has been argued that the perceived failure of health professionals to improve compliance rates with PD regimens is because ‘compliance’ itself has never been adequately conceptualized or defined; thus, it is difficult to operationalize and quantify. This paper examines how a group of Australian renal nurses construct patient compliance with PD therapy. These empirical data illuminate how PD compliance operates in one practice setting; how it is characterized by multiple and often competing energies; and how ultimately it might be pointless to try to tame ‘compliance’ through rigid definitions and measurement, or to rigidly enforce it in PD patients. The energies involved are too fractious and might be better spent, as many of the more experienced nurses in this study argue, in augmenting the energies that do work well together to improve patient outcomes.

Disturbed appetite and nutrient intake in peritoneal dialysis patients

OBJECTIVE Malnutrition is common among peritoneal dialysis (PD) patients. Reduced nutrient intake contributes to this. It has long been assumed that this reflects disturbed appetite. We set out to define the appetite profiles of a group of PD patients using a novel technique. DESIGN Prospective, cross-sectional comparison of PD patients versus controls. SETTING Teaching hospital dialysis unit. PATIENTS 39 PD patients and 42 healthy controls. INTERVENTION Visual analog ratings were recorded at hourly intervals to generate daily profiles for hunger and fullness. Summary statistics were generated to compare the groups. Food intake was measured using 3-day dietary records. MAIN OUTCOME MEASURES Hunger and fullness profiles. Derived hunger and fullness scores. RESULTS Controls demonstrated peaks of hunger before mealtimes, with fullness scores peaking after meals. The PD profiles had much reduced premeal hunger peaks. A postmeal reduction in hunger was evident, but the rest of the trace was flat. The PD fullness profile was also flatter than in the controls. Mean scores were similar despite the marked discrepancy in the profiles. The PD group had lower peak hunger and less diurnal variability in their hunger scores. They also demonstrated much less change in fullness rating around mealtimes, while the mean and peak fullness scores were little different. The reported nutrient intake was significantly lower for PD. CONCLUSION The data suggest that PD patients normalize their mean appetite perception at a lower level of nutrient intake than controls, suggesting that patient-reported appetite may be misleading in clinical practice. There is a loss of the usual daily variation for the PD group, which may contribute to their reduced food intake. The technique described here could be used to assess the impact of interventions upon the abnormal PD appetite profile.

Compliance, normality and the patient on peritoneal dialysis

Monitoring and enhancing patient compliance with peritoneal dialysis (PD) is a recurring and problematic theme in the renal literature. A growing body of literature also argues that a failure to understand the patient's perspective of compliance may be contributing to these problems. The aim of this study was to understand the concept of compliance with PD from the patient's perspective. Using the case study approach recommended by Stake (1995), five patients on PD consented to in-depth interviews that explored the meaning of compliance in the context of PD treatment and lifestyle regimens recommended by health professionals. Participants also discussed factors that influenced their choices to follow, disregard, or refine these regimens. Results indicate that health professionals acting in alignment with individual patient needs and wishes, and demonstrating an awareness of the constraints under which patients operate and the strengths they bring to their treatment, may be the most significant issues to consider with respect to definitions of PD compliance and the development of related compliance interventions. Aspects of compliance that promoted relative normality were also important to the participants in this study and tended to result in greater concordance with health professionals' advice.

Compliance, peritoneal dialysis and chronic kidney disease : lessons from the literature

Poor patient compliance with peritoneal dialysis (PD) has significant adverse effects on morbidity and mortality rates in individuals with chronic kidney disease (CKD). It also adds to the resource burdens of healthcare services and providers. This paper explores the notion of PD compliance in patients with CKD with reference to the relevant published literature. The analysis of the literature reveals that ‘PD compliance’ is a complex and challenging construct for both patients and health professionals. There is no universal definition of compliance that is widely adopted in practice and research, and therefore a lack of consensus on how to determine ‘compliant’ patient outcomes. There are also multiple and interconnected determinants of PD compliance that are context-bound, which healthcare professionals must be aware of, and which makes producing consensus of measuring PD compliance difficult. The complexity of the interventions required to produce even a modest improvement in PD compliance, which are described in this paper, are significant. Compliance with PD and other treatments for CKD is a multidimensional, context-bound concept, that to date has tended to efface the role and needs of the renal patient. We conclude the paper with the implications for contemporary practice.

Oral intake and serum levels of ascorbic acid in continuous ambulatory peritoneal dialysis patients

Oral intake of ascorbic acid is essential for optimum health in human beings. Continuous ambulatory peritoneal dialysis (CAPD) patients have an increased need for ascorbic acid, because of increased loss through dialysate, reduced intake owing to nausea and loss of appetite, and increased oxidative stress. However, optimum intake is still controversial. We studied 50 clinically stable patients to determine the relationship between oral ascorbic acid intake and serum ascorbic acid (SAA) level. Total oral intake ranged from 28 mg daily to 412 mg daily. Only one patient had an oral intake of ascorbic acid below 60 mg per day. The SAA levels ranged from 1 mg/L to 36.17 mg/L. Although a strong correlation existed between intake and SAA (p < 0.001, R2 = 0.47), the variation in SAA at any given intake level was wide. Of the studied patients, 62% had an SAA < 8.7 mg/L, 40% had an SAA < 5.1 mg/L (below the level in a healthy population), and 12% had a level below 2 mg/L (scorbutic). None of the patients demonstrated clinical manifestations of scurvy. Our results show that, in CAPD patients, ascorbic acid deficiency can be reliably detected only with SAA measurements, and oral intake may influence SAA level. To maintain ascorbic acid in the normal range for healthy adults, daily oral intake needs to be increased above the U.S. recommended dietary allowance to 80-140 mg.

Evolving progress in oncologic and operative outcomes for esophageal and junctional cancer : lessons from the experience of a high-volume center

Objective: Modern series from high-volume esophageal centers report an approximate 40% 5-year survival in patients treated with curative intent and postoperative mortality rates of less than 4%. An objective analysis of factors that underpin current benchmarks within high-volume centers has not been performed. Methods: Three time periods were studied, 1990 to 1998 (period 1), 1999 to 2003 (period 2), and 2004 to 2008 (period 3), in which 471, 254, and 342 patients, respectively, with esophageal cancer were treated with curative intent. All data were prospectively recorded, and staging, pathology, treatment, operative, and oncologic outcomes were compared. Results: Five-year disease-specific survival was 28%, 35%, and 44%, and in-hospital postoperative mortality was 6.7%, 4.4%, and 1.7% for periods 1 to 3, respectively (P < .001). Period 3, compared with periods 1 and 2, respectively, was associated with significantly (P < .001) more early tumors (17% vs 4% and 6%), higher nodal yields (median 22 vs 11 and 18), and a higher R0 rate in surgically treated patients (81% vs 73% and 75%). The use of multimodal therapy increased (P < .05) across time periods. By multivariate analysis, age, T stage, N stage, vascular invasion, R status, and time period were significantly (P < .0001) associated with outcome. Conclusions: Improved survival with localized esophageal cancer in the modern era may reflect an increase of early tumors and optimized staging. Important surgical and pathologic standards, including a higher R0 resection rate and nodal yields, and lower postoperative mortality, were also observed. Copyright © 2012 by The American Association for Thoracic Surgery.

Serum 25-hydroxy vitamin D concentrations are more deficient/insufficient in peritoneal dialysis than haemodialysis patients in a sunny climate

Background Research has identified associations between serum 25(OH)D and a range of clinical outcomes in chronic kidney disease and wider populations. The present study aimed to investigate vitamin D deficiency/insufficiency in dialysis patients and the relationship with vitamin D intake and sun exposure. Methods A cross-sectional study was used. Participants included 30 peritoneal dialysis (PD) (43.3% male; 56.87 ± 16.16 years) and 26 haemodialysis (HD) (80.8% male; 63.58 ± 15.09 years) patients attending a department of renal medicine. Explanatory variables were usual vitamin D intake from diet/supplements (IU day−1) and sun exposure (min day−1). Vitamin D intake, sun exposure and ethnic background were assessed by questionnaire. Weight, malnutrition status and routine biochemistry were also assessed. Data were collected during usual department visits. The main outcome measure was serum 25(OH)D (nm). Results Prevalence of inadequate/insufficient vitamin D intake differed between dialysis modality, with 31% and 43% found to be insufficient (<50 nm) and 4% and 33% found to be deficient (<25 nm) in HD and PD patients, respectively (P < 0.001). In HD patients, there was a correlation between diet and supplemental vitamin D intake and 25(OH)D (ρ = 0.84, P < 0.001) and average sun exposure and 25(OH)D (ρ = 0.50, P < 0.02). There were no associations in PD patients. The results remained significant for vitamin D intake after multiple regression, adjusting for age, gender and sun exposure. Conclusions The results highlight a strong association between vitamin D intake and 25(OH)D in HD but not PD patients, with implications for replacement recommendations. The findings indicate that, even in a sunny climate, many dialysis patients are vitamin D deficient, highlighting the need for exploration of determinants and consequences.

How does symptom burden differ in people with advanced CKD who are non-dialysis or currently receiving dialysis?

Background Chronic kidney disease (CKD) leads to a range of symptoms which are often under-recognised. Little is known about the full range of symptoms, particularly in who are pre-dialysis. Understanding symptom prevalence, distress, severity and frequency will help prioritise symptom management. Aims To examine symptom burden in advanced CKD (stages 4 and 5) and compare the symptom experience between those receiving dialysis or those who are pre-dialysis. Methods Using a cross-sectional design, a convenience sample of 436 people from three hospitals completed the Modified Dialysis Symptom Index (MDSI). Demographic and renal history data was also collected. Based on the 32 symptoms, we compared the prevalence, severity, distress and frequency of each symptom by treatment modality. Results Mean age was 48 years (range 18-87 years) and 53% were male. 75.5% (haemodialysis = 287; peritoneal dialysis = 42) were receiving dialysis and 24.5% (n = 107) were pre-dialysis. Overall, the mean symptom prevalence was 12.6 ± 7.9 and the most prevalent symptoms were fatigue (77%), bone or joint pain (60.3%) and itching (59.6%) across all CKD groups. The distress, severity and frequency of the symptoms were higher in the dialysis group. However, a higher frequency of psychological symptoms (worrying, feeling nervous and depression) were reported in the pre-dialysis group. Implication for clinical practice Patients with advanced CKD have a high symptom burden with those who are pre-dialysis needing greater psychological support. The MDSI could be used in nursing practice to screen patients for symptoms which could lead to timely and appropriate interventions.

Colonoscopy preparation in children: Safety, efficacy, and tolerance of high- versus low-volume cleansing methods

Background: The use of large-volume electrolyte balanced solutions as preparation for colonoscopy often results in poor patient compliance and acceptance. The tolerance, safety, and efficacy of high-versus low volume colon-cleansing methods as preparation for colonoscopy in children were compared by randomized operator-blinded trial. Methods: Twenty-nine children ages 3.6-14.6 years had either high-volume nasogastric balanced polyethylene glycol electrolyte lavage (20 ml/kg/h) until the effluent was clear (n = 15), or two oral doses of sodium phosphate solution (22.5-45 ml) separated by oral fluid intake (n = 14). Results: Both preparations were equally effective. The low-volume preparation was better tolerated and caused less discomfort that the high-volume preparation, judging by serial nurse observations. The incidence of abdominal symptoms, diarrhea, sleep disturbance, and vomiting was not significantly different between the two groups. Both groups had a small reduction in mean hematocrit and serum calcium levels. The sodium phosphate preparation caused increases in mean serum sodium concentrations from 140 to 145 mmol/L and serum phosphate concentrations from 1.41 to 2.53 mmol/L. Ten hours after the commencement of the preanesthetic fast, these concentrations had returned to normal. Conclusions: There are advantages in terms of tolerance, discomfort, and case of administration with acceptable colonic cleansing with the use of the less-invasive oral sodium phosphate low-volume colon-cleansing preparation in children. Safe use requires ensuring an adequate oral fluid intake during the preparation time and avoidance of use in patients with renal insufficiency.