To assess whether aerobic exercise training is an effective and an alternative method to control blood pressure (BP) in hypertension, 32 uncomplicated, never treated patients suffering from mild-to-moderate essential arterial hypertension (EAH) were included in an aerobic exercise training program using a regular standardized cycle ergometer exercise for 3 months. In all EAH patients, before and after the exercise training period, ambulatory BP monitoring (ABPM) was performed and several metabolic variables were assessed. Before exercise, in 20 EAH patients, a 48-h ABPM showed a normal day-night rhythm, with nocturnal BP decrease, according to a dipper-type hypertension, whereas in 12 EAH patients 48-h ABPM profile indicated a nondipper-type hypertension. After exercise, EAH dippers presented a significant decrease in the daytime systolic and diastolic BP, whereas EAH nondippers did not show any change in daytime and nighttime systolic and diastolic BP. Our study confirms the controversy about the postulated BP lowering effect of dynamic exercise in EAH patients, in the sense that only EAH dipper patients seem to obtain a beneficial diurnal lowering BP effect deriving from exercise, possibly through a reduction in sympathetic tone. On the contrary, physical activity seems to fail in reducing diurnal and nocturnal BP values in EAH nondippers, suggesting that in nondipper-type hypertension, other "masking" endogenous or exogenous factors could interfere with and prevail over the adrenergic-vagal balance that modulates the day-night BP synchronism.

The peritoneal catheter should be a permanent and safe access to the peritoneal cavity. Catheter-related problems are often the cause of permanent transfer to hemodialysis (HD) in up to 20% of peritoneal dialysis (PD) patients; in some cases, these problems require a temporary period on HD. Advances in connectology have reduced the incidence of peritonitis, and so catheter-related complications during PD have become a major concern. In the last few years, novel techniques have emerged in the field of PD: new dialysis solutions, better connectology, and cyclers for automated PD. However, extracorporeal dialysis has continued to improve in terms of methods and patient survival, but PD has failed to do so. The main reason is that peritoneal access has remained problematical. The peritoneal catheter is the major obstacle to widespread use of PD. Overcoming catheter-related problems means giving a real chance to development of the peritoneal technique. Catheters should be as efficient, safe, and acceptable as possible. Since its introduction in the mid-1960s, the Tenckhoff catheter has not become obsolete: dozens of new models have been proposed, but none has significantly reduced the predominance of the first catheter. No convincing prospective data demonstrate the superiority of any peritoneal catheter, and so it seems that factors other than choice of catheter are what affect survival and complication rates. Efforts to improve peritoneal catheter survival and complication rates should probably focus on factors other than the choice of catheter. The present article provides an overview of the characteristics of the best-known peritoneal catheters.

Dislocation of peritoneal dialysis catheters is one of the major causes of technique failure. We evaluated 701 Vicenza catheters, implanted since 1985 in 365 males, mean age 53 ± 16 yrs, range 24 - 87, and 336 females, mean age 51 ± 17 yrs, range 21 - 82. The Vicenza catheter is defined “short” since it consists of a classic straight double cuff PD catheter having however an inner segment (the portion located in the peritoneal cavity) much shorter than any other type of catheter. It is implanted in the lower abdomen, just a few centimeters above the pubis. The analysis of our results obtained in a large PD population displayed good device survival at 2 and 5 years (94.3% and 91.5% respectively), a low dislocation rate (4%) and an exit-site infection rate similar to other double cuffed catheters. There was no selection of patients receiving this catheter since from 1985 we have used this catheter in every incident patient. Due to its lower implantation site this catheter demonstrates excellent wearability and good body image acceptance.

To perform CFPD, a two way access must be available in order to allow continuous inflow and outflow of the solution. This is most likely achieved with a double lumen peritoneal catheter. To design a double lumen catheter does not necessarily mean to increase the size of the tube or to increase the discomfort of the patient. However, the real challenge is to find a design in which minimal re-circulation is experienced. The two tips of the catheter must be positioned such that a maximal exposure of the peritoneal surface to the fluid is guaranteed during one single passage of the fluid from one lumen to another. Double lumen catheters with one short branch and another long of straight and of spiral shape were originally designed. Ash and coworkers have designed a catheter with a t-shape configuration in order to distantiate to the maximum the tips of the two lumens. Recently we have designed a novel catheter for CFPD equipped with a thin walled silicone diffuser used to gently diffuse the inflow dialysate into the peritoneum. The holes on the round tapered diffuser are positioned to allow dialysate to perpendicularly exit 360 degrees from the diffuser. The diffuser design and hole locations disperse the high-flow dialysate fluid at 360 degrees, reducing trauma to the peritoneal walls and allowing the dialysate to mix into the peritoneum. The dispersed fluid infused into the peritoneal cavity is then drained through the second lumen whose tip is placed into the lower Douglas cavity. The new catheter with diffuser is also equipped with a special removable hub that allows for easy creation of the subcutaneous tunnel without increasing the size of the skin exit site. The results so far achieved seems to offer advantages in terms of high flows, minimal pressure regimes and negligible recirculation.

The real integration of a specific therapy into the renal replacement program is represented by the possibility of easy and free patient transfer from one treatment to another without restrictions. In the case of peritoneal dialysis we feel that its integration in the therapeutic approach of uremia represents an ethical obligation for the physician, a clinical opportunity for the patient and a good cost/benefit solution for care givers. A full conviction that peritoneal dialysis represents a real therapeutic option for ESRD patients is necessary to achieve a real integration of this therapy in the uremia treatment program. A positive cost benefit ratio, both from the clinical and the economical points of view must also be seeked. The patient indirectly, must receive the same positive conviction, based on solid data and clinical results, comparable to those achievable in hemodialysis. Furthermore the patient must know that such treatment will provide an equal opportunity for kidney transplant compared to other therapies. Such a kind of feeling and knowledge must include information on patient's survival, rate of complications, treatment adequacy, availability of different techniques within the treatment and complete summary of advantages and disadvantages.

Automated peritoneal dialysis (APD) has undergone substantial growth in recent years because of an increased demand for higher doses of peritoneal dialysis (PD) treatment and a need to improve quality of life for patients. The evolution of this treatment is closely linked with the development of new automatic machines and with recent advances in prescription and monitoring of PD treatment. In the present article, we describe the characteristics of the new generation of APD cyclers with particular regard to adequacy targets and safety. There is renewed interest in continuous-flow peritoneal dialysis (CFPD), because of a belief that new peritoneal access technologies will make the success of this modality a possibility. In the CFPD technique, a certain amount of fluid is constantly present in the abdomen, and constant inflow and outflow are maintained without interruption thanks to paired indwelling catheters. The PD solution is used either in a single pass or in a recirculation loop with a regeneration systems (sorbent cartridge or dialyzer).

Fluid overload and uncontrolled hypertension may be considered important mortality risk factors in peritoneal dialysis (PD) population. Even malnutrition is highly prevalent in PD patients. It is now well established that lower levels of serum markers of nutrition such as albumin, creatinine, and prealbumin are associated with increased mortality in PD patients [Fein, P.A. et al: Adv Perit Dial 2002;18:195-199]. Moreover cardiovascular disease is a leading cause of death in patients with end-stage renal disease, and hypertension and volume expansion are highly prevalent in long-term PD patients. Many studies in hemodialysis and in PD have demonstrated that phase sensitive bioelectrical impedance analysis is a widely used and proven method for evaluating patient's body composition. The vectorial bioimpedance analysis is a validated system to evaluate the hydration and nutritional state of hemodialysis and PD patients with acceptable sensitivity and specificity. The aim of this study is to evaluate the reliability and accuracy of the new multifrequency BodyComp bioimpedance analyzer as a home based tool versus traditional Bia Vector.

Peritoneal catheter exit-site and tunnel infections remain critical problems in patients undergoing peritoneal dialysis. Catheter-related peritonitis occurs in about 20% of patients and exit-site infections are responsible for catheter removal in more than one-fifth of the cases. For the last 2 years in the Department of Nephrology, San Bortolo Hospital, Vicenza, Italy, we have been treating exit-site infections caused by Pseudomonas with sodium hypochlorite packs as well as systemic and local antibiotic therapy. Considering the encouraging results obtained on Pseudomonas infection, we decided to utilize the same schedule for the treatment of exit-site infections caused by other germs which are generally difficult to eradicate to prevent peritonitis and catheter removal. Between 2003 and 2004, 10 patients contracted infection of the exit-site. All patients underwent a swab test because of the reddening and the purulent secretion of the exit-site. The swab resulted positive for Pseudomonas in 7 patients, Corynebacterium sp. in 2 patients, and Candida albicans in 1 patient. All patients were treated with systemic antibiotic therapy or antifungal therapy, local sodium hypochlorite 50% packs. After 15 days all patients were submitted to a swab test of the exit site. In all patients, the swab test resulted negative after 15 days and 1 month, and they could continue peritoneal dialysis. This procedure avoided peritoneal catheter removal and temporary switch to hemodialysis in all patients with exit site infection. The mechanism of action is related to the wide antimicrobial spectrum and the rapid action of sodium hypochlorite possibly creating a protective barrier on the exit-site.