Over-hydration is common in asymptomatic Chinese PD patients. The degree of over-hydration is particularly pronounced in patients who are inadequately dialyzed, have multiple comorbid conditions and low serum albumin levels. Over-hydration is associated with high blood pressure and arterial stiffness, and may contribute to the excessive risk of cardiovascular disease in this group of patients.

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♦ Background: Studies in hemodialysis patients suggest that the "surprise" question can help to identify a group of patients with a high mortality risk who should receive priority for palliative care interventions. However, the same instrument has not been tested in peritoneal dialysis (PD) patients. ♦ Method: We studied 367 prevalent PD patients from a single dialysis center. Three clinicians independently answered the "surprise" question (Would I be surprised if this patient died within the next 12 months?) according to their clinical impression of the individual patient. Patients are then classified into "yes" (yes, surprised) and "no" (no, not surprised) groups. All patients were followed for 12 months. ♦ Results: In this cohort, 109 patients (29.7%) were allocated to the "no" group, and 258 (70.3%), to the "yes" group. Patients in the "no" group were older and had high prevalences of pre-existing ischemic heart disease, cerebrovascular disease, and peripheral vascular disease. The "no" group had a higher score on the Charlson comorbidity index and a higher malnutrition-inflammation score. At 12 months, 44 patients had died. Mortality was 24.8% in the "no" group and 6.6% in the "yes" group. Multivariate analysis showed that an opinion of "Not surprised if dies in the next 12 months" was an independent predictor of 12-month mortality, with an associated 3.594 excess mortality risk (95% confidence interval: 1.411 to 9.151; p = 0.007). The positive predictive value of this opinion was 24.8%, and its negative predictive value was 93.4%. ♦ Conclusions: The "surprise" question has the potential to help identify a group of PD patients with high short-term mortality. Its use may contribute to a decision to refer PD patients for early palliative care assessment.

BackgroundFluid overload is common among asymptomatic peritoneal dialysis (PD) patients. We aim to determine the prevalence and prognostic significance of fluid overload, as measured by bioimpedance spectroscopy, in asymptomatic incident PD patients.MethodsWe performed a single-center study on 311 incident PD patients. Volume status was represented by the volume of overhydration (OH), OH/extracellular water (ECW) ratio, ECW/total body water (TBW) ratio, and ECW to intracellular water (ICW) ratio (E:I ratio). Patient survival, technique survival and cardiovascular event-free survival were determined.ResultsThe median period of follow up was 27.3 months. Fluid overload was present in 272 patients (87.5%) when defined as OH volume over 1.1L. All hydration parameters significantly correlated with Charlson Comorbidity Index, and inversely with total Kt/V, and serum albumin. Multivariate cause-specific Cox analysis showed that volume status independently predicted patient survival; every 0.1 unit increase in E:I ratio was associated with 24.5% increase in all-cause mortality (adjusted cause-specific hazard ratio [ACSHR] 1.245, p = 0.002). Hydration status was also an independent predictor of cardiovascular event-free survival after excluding hospital admission for congestive heart failure; each 0.1 unit increase in E:I ratio was associated with 18.7% decrease in cardiovascular event-free survival (ACSHR 1.187, p = 0.011). In contrast, hydration parameters were not associated with technique survival.ConclusionsFluid overload is common in asymptomatic incident PD patients and is a strong predictor of patient survival and cardiovascular event. The impact of bioimpedance spectroscopy-guided fluid management on the outcome of PD patients deserves further study.

Background/Aims: Previous studies showed that frailty is prevalent in both pre-dialysis and dialysis patients. However, the prevalence and prognostic implication of frailty in Chinese peritoneal dialysis (PD) patients remain unknown. Methods: We used a validated questionnaire to determine the Frailty Score of 193 unselected prevalent PD patients. All patients were then followed for 2 years for their need of hospitalization and mortality. Results: Amongst the 193 patients, 134 (69.4%) met the criteria of being frail. Frailty Score significantly correlated with Charlson's comorbidity score (r = 0.40, p < 0.0001), Malnutrition Inflammation Score (r = 0.59, p < 0.0001), and inversely with Subjective Global Assessment score (r = -0.44, p < 0.0001). Frailty was closely associated with the need of hospitalization. Patients with nil, mild, moderate, and severe frailty required 2.4 ± 6.0, 1.6 ± 1.6, 2.7 ± 2.5, 5.2 ± 4.8 hospital admissions per year, respectively (p < 0.0001), and they stayed in hospital for 6.4 ± 9.2, 5.3 ± 6.2, 10.0 ± 10.4, 12.9 ± 20.1 days per hospital admission, respectively (p < 0.0001). However, Frailty Score was not an independent predictor of patient or technique survival. Conclusions: Frailty is prevalent among Chinese PD patients. Frail PD patients have a high risk of requiring hospitalization and their hospital stay tends to be prolonged. Early identification may allow timely intervention to prevent adverse health outcomes in this group of patients.

BackgroundCirculating bacterial DNA fragment is related to systemic inflammatory state in peritoneal dialysis (PD) patients. We hypothesize that plasma bacterial DNA level predicts cardiovascular events in new PD patients.MethodsWe measured plasma bacterial DNA level in 191 new PD patients, who were then followed for at least a year for the development of cardiovascular event, hospitalization, and patient survival.ResultsThe average age was 59.3 ± 11.8 years; plasma bacterial DNA level 34.9 ± 1.5 cycles; average follow up 23.2 ± 9.7 months. At 24 months, the event-free survival was 86.1%, 69.8%, 55.4% and 30.8% for plasma bacterial DNA level quartiles I, II, III and IV, respectively (p < 0.0001). After adjusting for confounders, plasma bacterial DNA level, baseline residual renal function and malnutrition-inflammation score were independent predictors of composite cardiovascular end-point; each doubling in plasma bacterial DNA level confers a 26.9% (95% confidence interval, 13.0 – 42.5%) excess in risk. Plasma bacterial DNA also correlated with the number of hospital admission (r = -0.379, p < 0.0001) and duration of hospitalization for cardiovascular reasons (r = -0.386, p < 0.0001). Plasma bacterial DNA level did not correlate with baseline arterial pulse wave velocity (PWV), but with the change in carotid-radial PWV in one year (r = -0.238, p = 0.005).ConclusionsCirculating bacterial DNA fragment level is a strong predictor of cardiovascular event, need of hospitalization, as well as the progressive change in arterial stiffness in new PD patients.

SummaryBackground and objectives The clinical behavior of repeat-peritonitis episodes, defined as peritonitis with the same organism occurring more than 4 weeks after completion of therapy for a prior episode, is poorly understood.Design, setting, participants, & measurements We compared outcomes of 181 episodes of repeat peritonitis from 1995 to 2009 (Repeat Group) with 91 episodes of relapsing peritonitis (Relapsing Group) and 125 episodes of peritonitis preceded 4 weeks or longer by another episode with a different organism (Control Group). ResultsIn Repeat Group, 24% were due to Staphylococcus aureus, as compared with 5.5% in Relapsing Group and 15% in Control Group. The majority of the organisms causing relapsing peritonitis were Gram negative (62%), whereas the majority of that in Repeat Group were Gram positive (56%). Repeat Group had a lower complete-cure rate (70.7% versus 54.9%) than Relapsing Group, but rates of primary response, catheter removal, and mortality were similar. Repeat Group had a higher primary response rate (89.0% versus 73.6%) and a lower rate of catheter removal (6.1% versus 15.2%) than Control Group, whereas the completecure rate and mortality were similar. Repeat Group had a higher risk of developing relapsing (14.3% versus 2.2%) and repeat peritonitis (26.1% versus 5.4%) than Control Group, whereas the risk of recurrent peritonitis was similar.Conclusions Repeat peritonitis is a distinct clinical entity. Although repeat-peritonitis episodes generally have a satisfactory response to antibiotic, they have a substantial risk of developing further relapsing or repeat peritonitis.

♦ ♦ ♦ ♦ ♦ Background: Peritoneal dialysis (PD) patients with severe peritonitis require catheter removal. It is often assumed that this approach, together with antibiotics, would eradicate the infection; however, some patients continue to have problems despite catheter removal. ♦ ♦ ♦ ♦ ♦ Method: We reviewed 30 consecutive PD patients in our center from 1997 to 2008 with recurrent loculated peritoneal collection after catheter removal for severe peritonitis. ♦ ♦ ♦ ♦ ♦ Results: Of the 1928 episodes of peritonitis that occurred in 702 patients during the study period, 11.1% required catheter removal and 1.6% developed recurrent peritoneal collection that required percutaneous drainage. Median time to diagnosis of intra-abdominal collection was 12 days after catheter removal (interquartile range 7 -61 days). In 25 patients (83.3%), aspirate of the abdominal collection was culture negative. In 17 patients (56.7%), the abdominal collection was recurrent and required repeated percutaneous aspiration. Only 3 patients had successful reinsertion of the peritoneal catheter but all had reduced small solute clearance after returning to PD. ♦ ♦ ♦ ♦ ♦ Conclusion: A small but not negligible proportion of patients with PD-related peritonitis develop recurrent intraabdominal collection that requires percutaneous drainage after catheter removal. The chance of a successful return to PD is very low in this group of patients. Direct conversion to long-term hemodialysis may avoid unnecessary attempts at peritoneal catheter reinsertion.