Publications by authors named "Stanley Fan"

80 Publications

Tackling Dialysis Burden around the World: A Global Challenge.

Kidney Dis (Basel) 2021 May 29;7(3):167-175. Epub 2021 Apr 29.

National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.

CKD is a global problem that causes significant burden to the healthcare system and the economy in addition to its impact on morbidity and mortality of patients. Around the world, in both developing and developed economies, the nephrologists and governments face the challenges of the need to provide a quality and cost-effective kidney replacement therapy for CKD patients when their kidneys fail. In December 2019, the 3rd International Congress of Chinese Nephrologists was held in Nanjing, China, and in the meeting, a symposium and roundtable discussion on how to deal with this CKD burden was held with opinion leaders from countries and regions around the world, including Australia, Canada, China, Hong Kong, Singapore, Taiwan, the UK, and the USA. The participants concluded that an integrated approach with early detection of CKD, prompt treatment to slow down progression, promotion of home-based dialysis therapy like peritoneal dialysis and home HD, together with promotion of kidney transplantation, are possible effective ways to combat this ongoing worldwide challenge.
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http://dx.doi.org/10.1159/000515541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8215964PMC
May 2021

Overcoming barriers and building a strong peritoneal dialysis programme - Experience from three South Asian countries.

Perit Dial Int 2021 Sep 2;41(5):480-483. Epub 2021 Jun 2.

Department of Nephrology, 243030Teaching Hospital, Kandy, Sri Lanka.

The development of peritoneal dialysis (PD) programmes in lower-resource countries is challenging. This article describes the learning points of establishing PD programmes in three countries in South Asia (Nepal, Sri Lanka and Pakistan). The key barriers identified were government support (financial), maintaining stable supply of PD fluids, lack of nephrologist and nurse expertise, nephrology community bias against PD, lack of nephrology trainee awareness and exposure to this modality. To overcome these barriers, a well-trained PD lead nephrologist (PD champion) is needed, who can advocate for this modality at government, professional and community levels. Ongoing educational programmes for doctors, nurses and patients are needed to sustain the PD programmes. Support from well-established PD centres and international organisations (International Society of Peritoneal Dialysis (ISPD), International Society of Nephrology (ISN), International Pediatric Nephrology Association (IPNA) are essential.
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http://dx.doi.org/10.1177/08968608211019986DOI Listing
September 2021

Relationship between sodium removal, hydration and outcomes in peritoneal dialysis patients.

Nephrology (Carlton) 2021 Aug 30;26(8):676-683. Epub 2021 Apr 30.

Departments of Renal Medicine and Transplantation, Barts Health NHS Trust, London, United Kingdom.

Background: Fluid overload (FO) in peritoneal dialysis (PD) patients is associated with mortality. We explore if low daily sodium removal is an independent risk factor for mortality. We examined severely FO PD patients established for >1 year in expectation that PD prescription would have been optimized for solute clearance and ultrafiltration. We also wish to determine the relationship between kt/v and sodium removal.

Methods: Retrospective analysis of 231 PD patients with FO ≥2.0 L and compared with 218 PD patients who were euvolaemic throughout their PD treatment. Patients were followed up until death censored for transplantation.

Results: Mean daily sodium removal in overhydrated patients was only 75 mmoles (=1.7 g). CAPD usage was more common in patients with the highest sodium removal. Achievement of UK guidelines for solute clearance and daily fluid removal were not independent predictors of mortality. Markers of sarcopenia (low serum albumin and high CRP) were associated with increased mortality, but these parameters were not independent predictors in a model that included functional assessment (Karnofsky score). Daily sodium removal was not predictive of mortality but the imprecision of clinically used sodium assay should be noted. The correlation between Na and kt/v is statistically significant but R was weak at .07.

Conclusion: While diabetic males were more likely to become overhydrated, these factors did not increase mortality further. Traditional targets of 'dialysis adequacy' did not predict survival. Kt/v is not a good indicator of sodium removal which can be surprisingly low. Measuring sodium clearance may help clinicians optimize PD modality (CAPD vs. APD).
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http://dx.doi.org/10.1111/nep.13885DOI Listing
August 2021

Persistent colonization of exit site is associated with modality failure in peritoneal dialysis.

Perit Dial Int 2020 Nov 23:896860820972598. Epub 2020 Nov 23.

Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK.

Exit-site infections (ESIs) increase the risk of developing peritoneal dialysis (PD) peritonitis and PD technique failure. There are no clear guidelines on how to monitor exit site (ES) after ESI with or . We report on a 1-year observational study of 23 patients who developed an ESI with one of these serious pathogens. After completing initial antibiotic treatment, swabs were taken every month for 3 months. Primary treatment cure occurred in 19/23 (83%). Colonization of ES after primary cure occurred in 8/19 (42%) patients. In the eight colonized patients, five had subsequent PD technique failure due to infections. By contrast, during an average follow-up period of 7.2 months, none of the 11 patients who were proven noncolonized developed PD technique failure from infections; HR (colonized vs. noncolonized) = 10.89, 95% CI 2.6-45.43, < 0.05. In conclusion, colonization significantly increased the risk of catheter loss. Increased surveillance and aggressive treatment may ameliorate this risk.
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http://dx.doi.org/10.1177/0896860820972598DOI Listing
November 2020

HEROIC: a 5-year observational cohort study aimed at identifying novel factors that drive diabetic kidney disease: rationale and study protocol.

BMJ Open 2020 09 9;10(9):e033923. Epub 2020 Sep 9.

Department of Nephrology, Barts Health NHS Trust, London, UK

Introduction: Diabetic kidney disease (DKD) is the leading cause of end-stage kidney disease worldwide and a major cause of premature mortality in diabetes mellitus (DM). While improvements in care have reduced the incidence of kidney disease among those with DM, the increasing prevalence of DM means that the number of patients worldwide with DKD is increasing. Improved understanding of the biology of DKD and identification of novel therapeutic targets may lead to new treatments. A major challenge to progress has been the heterogeneity of the DKD phenotype and renal progression. To investigate the heterogeneity of DKD we have set up The East and North London Diabetes Cohort (HEROIC) Study, a secondary care-based, multiethnic observational study of patients with biopsy-proven DKD. Our primary objective is to identify histological features of DKD associated with kidney endpoints in a cohort of patients diagnosed with type 1 and type 2 DM, proteinuria and kidney impairment.

Methods And Analysis: HEROIC is a longitudinal observational study that aims to recruit 500 patients with DKD at high-risk of renal and cardiovascular events. Demographic, clinical and laboratory data will be collected and assessed annually for 5 years. Renal biopsy tissue will be collected and archived at recruitment. Blood and urine samples will be collected at baseline and during annual follow-up visits. Measured glomerular filtration rate (GFR), echocardiography, retinal optical coherence tomography angiography and kidney and cardiac MRI will be performed at baseline and twice more during follow-up. The study is 90% powered to detect an association between key histological and imaging parameters and a composite of death, renal replacement therapy or a 30% decline in estimated GFR.

Ethics And Dissemination: Ethical approval has been obtained from the Bloomsbury Research Ethics Committee (REC 18-LO-1921). Any patient identifiable data will be stored on a password-protected National Health Services N3 network with full audit trail. Anonymised imaging data will be stored in a ISO27001-certificated data warehouse.Results will be reported through peer-reviewed manuscripts and conferences and disseminated to participants, patients and the public using web-based and social media engagement tools as well as through public events.
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http://dx.doi.org/10.1136/bmjopen-2019-033923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482453PMC
September 2020

Comparison between standard single chamber versus dual chamber low glucose degradation product peritoneal dialysis fluids.

Artif Organs 2021 Jan 30;45(1):88-94. Epub 2020 Jul 30.

UCL Department of Nephrology, Royal Free Hospital, University College London, London, UK.

Dual chamber (DC) peritoneal dialysis (PD) dialysates contain fewer glucose degradation products (GDPs), so potentially reducing advanced glycosylation end products (AGEs), which have been reported to increase inflammation and cardiovascular risk. We wished to determine whether use of DC dialysates resulted in demonstrable patient benefits. Biochemical profiles, body composition, muscle strength, and skin autofluorescence measurements of tissue AGEs (SAF) were compared in patients using DC and standard single chamber dialysates. We studied 263 prevalent PD patients from 2 units, 62.4% male, mean age 61.8 ± 16.1 years, 78 (29.7%) used DC dialysates. DC patients were younger (55.9 ± 16.4 vs. 64.2 ± 15.4 years), and more had lower Davies comorbidity score (median 1 (0-1) vs. 1 (0, 2)), slower peritoneal transport (D/P creatinine 0.67 ± 0.12 vs. 0.73 ± 0.13), greater extracellular water-to-total body water (ECW/TBW) ratio (0.46 ± 0.05 vs. 0.42 ± 0.06), all P < .001, whereas there were no differences in the duration of PD (median (IQR) 19 (8-32) vs. 14 (8-23) months), residual renal function (Kt/V 0.71 ± 0.71 vs. 0.87 ± 0.82), urine volume (642 (175-1200) vs. 648 (300-1200) mL/day), hand grip strength (26.9 ± 10.5 vs. 24.9 ± 10.7 kg), C-reactive protein (4(1-10) vs. 4(2-12) mg/L), and SAF (median 3.60 (3.02, 4.40) vs. 3.50 (3.00, 4.23)) AU. In our cross-sectional observational study, we were not able to show a demonstrable advantage for using low GDP dialysates over conventional glucose dialysates, in terms of biochemical profiles, residual renal function, muscle strength, or tissue AGE deposition. More patients using low GDP dialysates were slower peritoneal transporters with higher ECW/TBW ratios.
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http://dx.doi.org/10.1111/aor.13768DOI Listing
January 2021

Single-dwell treatment with a low-sodium solution in hypertensive peritoneal dialysis patients.

Perit Dial Int 2020 09 19;40(5):446-454. Epub 2020 May 19.

206662Fresenius Medical Care, Bad Homburg, Germany.

Background: Patients on peritoneal dialysis (PD) may suffer from sodium (Na) and fluid overload, hypertension and increased cardiovascular risk. Low-Na dialysis solution, by increasing the diffusive removal of Na, might improve blood pressure (BP) management.

Methods: A glucose-compensated, low-Na PD solution (112 mmol/L Na and 2% glucose) was compared to a standard-Na solution (133 mmol/L Na and 1.5% glucose) in a prospective, randomised, single-blind study in hypertensive patients on PD. One daily exchange of the standard dialysis regimen was substituted by either of the study solutions for 6 months. The primary outcome (response) was defined as either a decrease of 24-h systolic BP (SBP) by ≥6 mmHg or a fall in BP requiring a medical intervention (e.g. a reduction of antihypertensive medication) at 8 weeks.

Results: One hundred twenty-three patients were assessed for efficacy. Response criteria were achieved in 34.5% and 29.1% of patients using low- and standard-Na solutions, respectively ( = 0.51). Small reductions in 24 h, office, and self-measured BP were observed, more marked with low-Na than with standard-Na solution, but only the between-group difference for self-measured SBP and diastolic BP was significant ( = 0.002 and = 0.003). Total body water decreased in the low-Na group and increased in the control group, but between-group differences were not significant. Hypotension and dizziness occurred in 27.0% and in 11.1% of patients in the low-Na group and in 16.9% and 4.6% in the control group, respectively.

Conclusions: Superiority of low-Na PD solution over standard-Na solution for control of BP could not be shown. The once daily use of a low-Na PD solution was associated with more hypotensive episodes, suggesting the need to reassess the overall concept of how Na-reduced solutions might be incorporated within the treatment schedule.
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http://dx.doi.org/10.1177/0896860820924136DOI Listing
September 2020

Polymerase chain reaction/electrospray ionization-mass spectrometry (PCR/ESI-MS) is not suitable for rapid bacterial identification in peritoneal dialysis effluent.

Perit Dial Int 2021 01 10;41(1):96-100. Epub 2020 Apr 10.

Renal Medicine and Transplantation, 9744Barts Health NHS Trust, London, UK.

Background: Peritoneal dialysis (PD)-related peritonitis is a serious complication of PD, but routine microbiological culture is slow and could not identify the organism in 15% cases. We examine the accuracy of polymerase chain reaction/electrospray ionization-mass spectrometry (PCR/ESI-MS), a PCR-based method developed for the direct detection of bacteria in blood, for rapid identification of microorganisms from PD effluent.

Methods: We recruited 73 consecutive patients with PD-related peritonitis. Dialysis effluent was collected for routine bacterial culture, PCR/ESI-MS, and bacterial DNA quantification before initiation of antibiotic therapy.

Results: By digital PCR with universal bacterial primers, bacterial DNA was detectable in all PD effluent specimens. For the entire cohort, taking standard bacterial culture as the gold standard, the PCR/ESI-MS assay correctly identified 34.3% of the causative organisms, failed to identify any organism in 52.1% cases, and identified a different organism in 8.2% cases. For the 14 episodes of peritonitis that were culture negative by conventional bacterial culture, the PCR/ESI-MS assay identified an organism in only four cases. The detection rate of the IRIDICA BAC BSI assay was not affected by the use of biocompatible PD solution or concomitant exit-site infection.

Conclusions: The PCR/ESI-MS assay could not identify the causative organism in over 50% of the PD effluent samples in patients with PD-related peritonitis and should be not used for such purpose. The reason for the poor performance needs further investigation.
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http://dx.doi.org/10.1177/0896860820917845DOI Listing
January 2021

The impact of volume overload on technique failure in incident peritoneal dialysis patients.

Clin Kidney J 2021 Feb 22;14(2):570-577. Epub 2019 Dec 22.

Department of Medicine, Zealand University Hospital, Roskilde, Denmark.

Background: Technique failure in peritoneal dialysis (PD) can be due to patient- and procedure-related factors. With this analysis, we investigated the association of volume overload at the start and during the early phase of PD and technique failure.

Methods: In this observational, international cohort study with longitudinal follow-up of incident PD patients, technique failure was defined as either transfer to haemodialysis or death, and transplantation was considered as a competing risk. We explored parameters at baseline or within the first 6 months and the association with technique failure between 6 and 18 months, using a competing risk model.

Results: Out of 1092 patients of the complete cohort, 719 met specific inclusion and exclusion criteria for this analysis. Being volume overloaded, either at baseline or Month 6, or at both time points, was associated with an increased risk of technique failure compared with the patient group that was euvolaemic at both time points. Undergoing treatment at a centre with a high proportion of PD patients was associated with a lower risk of technique failure.

Conclusions: Volume overload at start of PD and/or at 6 months was associated with a higher risk of technique failure in the subsequent year. The risk was modified by centre characteristics, which varied among regions.
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http://dx.doi.org/10.1093/ckj/sfz175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886558PMC
February 2021

Quality of life with conservative care compared with assisted peritoneal dialysis and haemodialysis.

Clin Kidney J 2019 Apr 20;12(2):262-268. Epub 2018 Jul 20.

St James University Hospital, Leeds, UK.

Background: There is little information about quality of life (QoL) for patients with end-stage kidney disease (ESKD) choosing conservative kidney management (CKM). The Frail and Elderly Patients on Dialysis (FEPOD) study demonstrated that frailty was associated with poorer QoL outcomes with little difference between dialysis modalities [assisted peritoneal dialysis (aPD) or haemodialysis (HD)]. We therefore extended the FEPOD study to include CKM patients with estimated glomerular filtration rate ≤10 mL/min/1.73 m (i.e. individuals with ESKD otherwise likely to be managed with dialysis).

Methods: CKM patients were propensity matched to HD and aPD patients by age, gender, ethnicity, diabetes status and index of deprivation. QoL outcomes measured were Short Form-12 (SF12), Hospital Anxiety and Depression Scale depression score, symptom score, Illness Intrusiveness Rating Scale (IIRS) and Renal Treatment Satisfaction Questionnaire. Frailty was assessed using the Clinical Frailty Scale. Generalized linear modelling was used to assess the impact of treatment modality on QoL outcomes, adjusting for baseline characteristics.

Results: In total, 84 (28 CKM, 28 HD and 28 PD) patients were included. Median age for the cohort was 82 (79-88) years. Compared with CKM, aPD was associated with higher SF12 physical component score (PCS) [Exp B (95% confidence interval) = 1.20 (1.00-1.45), P < 0.05] and lower symptom score [Exp B = 0.62 (0.43-0.90), P = 0.01]; depression score was lower in HD compared with CKM [Exp B = 0.70 (0.52-0.92), P = 0.01]. Worsening frailty was associated with higher depression scores [Exp B = 2.59 (1.45-4.62), P < 0.01], IIRS [Exp B = 1.20 (1.12-1.28), P < 0.01] and lower SF12 PCS [Exp B = 0.87 (0.83-0.93), P < 0.01].

Conclusion: Treatment by dialysis, both with aPD and HD, improved some QoL measures. Overall, aPD was equal to or slightly better than the other modalities in this elderly population. However, as in the primary FEPOD study, frailty was associated with worse QoL measures irrespective of CKD modality. These findings highlight the need for an individualized approach to the management of ESKD in older people.
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http://dx.doi.org/10.1093/ckj/sfy059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6452183PMC
April 2019

Performance of Gram Stains and 3 Culture Methods in the Analysis of Peritoneal Dialysis Fluid.

Perit Dial Int 2019 Mar-Apr;39(2):190-192

Division of Infection, Barts Health NHS Trust, Royal London Hospital, Whitechapel Road, London, UK.

Microbiological diagnosis of peritoneal dialysis (PD)-related peritonitis includes PD fluid cell count, Gram stain, and culture, as recommended by the International Society for Peritoneal Dialysis. In this retrospective study, we examined the utility of Gram stains and compared 3 culture methods.We examined a laboratory cohort (samples sent to the laboratory for any reason; = 251) and a clinical cohort (samples sent from patients felt clinically to have peritonitis; = 264). Culture positivity rates were higher in the clinical cohort (39.4%) than the laboratory cohort (21.5%), with no difference in the distribution of organisms between the cohorts; cell counts were significantly higher in culture-positive samples in both cohorts.Rates of positivity in the laboratory and clinical cohorts, respectively, were as follows: Gram stains 1.9% and 7.7%; direct plate culture 13% and 30.8% and "bedside" inoculated blood culture bottles 82.1% and 92.8%. Enrichment culture was never negative when another method was positive.Our data indicate that enrichment culture can be used as a single culture methodology for analyzing PD fluid without loss of sensitivity. They also suggest that Gram stains are of relatively low yield; consideration could be given to ceasing their routine performance provided that broad antimicrobial therapy is administered pending culture results.
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http://dx.doi.org/10.3747/pdi.2018.00087DOI Listing
January 2020

Clinical Value of Screening Peritoneal Dialysis Patients for Bacterial Colonization or Contamination.

Perit Dial Int 2019 Mar-Apr;39(2):126-133. Epub 2019 Feb 9.

Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK

Introduction: The adoption of the International Society for Peritoneal Dialysis guideline of using mupirocin ointment has been limited by fear of developing mupirocin-resistant organisms. We performed a surveillance program of a large peritoneal dialysis (PD) unit.

Methods: We performed 1,175 surveillance swabs from anterior nares, PD catheter exit site, groin, and axilla, from 240 patients. The mean interval between swabs was 3.3 months.

Results: Colonization by () or species was 9.5% and 10.9%, respectively. Despite adopting a universal policy of applying mupirocin to PD catheter exit sites in 2001, no instances of mupirocin-resistant were identified. Moreover, patients who grew from surveillance swabs did not experience higher peritonitis rates than those with "no growth." This was in contrast to patients who grew or enteric organisms. There were no differences in patient demographics for those who grew , , or enteric organisms (compared with "no-growth" patients).

Conclusion: Our results suggest that the application of mupirocin ointment appeared to minimize peritonitis of patients colonized with . The use of mupirocin in this patient cohort has not led to mupirocin resistance. The increased peritonitis rate of patients who grew or enteric organisms is of interest. We propose that greater attention to hygiene and catheter care in these patients is warranted. The increasing use of paid healthcare workers attending patients daily to help perform PD (assisted PD) gives an opportunity for us to address these wider issues.
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http://dx.doi.org/10.3747/pdi.2018.00082DOI Listing
January 2020

Clinical value of body composition monitor to evaluate lean and fat tissue mass in peritoneal dialysis.

Eur J Clin Nutr 2019 11 15;73(11):1520-1528. Epub 2019 Jan 15.

Departments of Renal Medicine and Transplantation, Barts Health NHS Trust, London, E1 1BB, UK.

Background/objectives: Bioimpedance analysis is often routinely performed in any dialysis unit to guide fluid management but can provide a reproduceable assessment of fat and muscle mass. We wished to determine the clinical significance of low muscle or high fat mass and the determinants that influence their change.

Subjects/methods: We performed retrospective analysis of 824 patients on peritoneal dialysis who underwent routine repeated bioimpedance analysis measurements using the body composition monitor (BCM).

Results: Lean tissue index (LTI) was an independent predictor of mortality when sex, age, PD vintage and diabetes status were included in the models (HR 0.93; 95% CI 0.86-1.00, p < 0.05) and when baseline serum albumin was included in a separate model (HR 0.86; 95% CI: 0.79-0.93, p < 0.001). High fat tissue index (FTI) was an independent predictor of mortality when demographic factors were included (HR 0.87; 95% CI: 0.78-0.97, p < 0.02), but not with the addition biochemical parameters. Changes in body composition of 206 patients over a 2-year follow-up period could not be predicted by baseline demographics, functional or biochemical assessments. However, there was a strong inverse relationship between changes in LTI and FTI. There were no associations between changes in body composition with prescribed dialysate glucose.

Conclusions: We showed body composition changes are common and complex. LTI was an independent predictor of survival. Changes in LTI and FTI could not be predicted by baseline parameters. BCM may be a sensitive and accurate tool to monitor changes in body composition during dialysis treatment.
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http://dx.doi.org/10.1038/s41430-019-0391-3DOI Listing
November 2019

Comparison of skin autofluorescence, a marker of tissue advanced glycation end-products in peritoneal dialysis patients using standard and biocompatible glucose containing peritoneal dialysates.

Nephrology (Carlton) 2019 Aug 2;24(8):835-840. Epub 2019 May 2.

UCL Department of Nephrology, Royal Free Hospital, University College London, London, UK.

Background: Heat sterilization of peritoneal dialysis (PD) dialysates leads to the generation of advanced glycation products (AGE), which can then deposit in the skin and be measured by skin autofluorescence (SAF). Newer biocompatible dual chamber dialysates contain less AGE. We wished to determine whether the use of these newer dialysates resulted in lower SAF.

Methods: Skin autofluorescence was measured using the AGE reader, which directs ultraviolet light, intensity range 300-420 nm (peak 370 nm) in patients established on PD for >3 months using glucose containing dialysates.

Results: We screened 196 consecutive patients, and measured SAF in 150; 86 (57.3%) male, median age 62 (53-71) years, median duration of PD treatment 17 (8.6-34.3) months. The median SAF was 3.48 (2.92-4.26) AU. The median SAF in the 57 (38%) patients prescribed biocompatible dual chamber bag dialysates was 3.39 (2.69-3.98) versus 3.5 (3.05-4.54) for those using standard dialysates (P = 0.044). Although prescription of biocompatible fluids was associated with SAF on univariate analysis, but not on multivariable testing, SAF was independently associated with Stoke-Davies co-morbidity grade (β 0.045, 95% confidence limits (CL) 0.015-0.075, P = 0.002), log duration of PD therapy (β 0.051, CL 0.001-0.101, P = 0.045), white ethnicity (β 0.066, CL 0.028-0.104, P = 0.001), and negatively with serum albumin (β -0.006, CL -0.008 to -0.004, P = 0.014).

Conclusion: Although SAF was lower in PD patients prescribed biocompatible dual chamber dialysates, on multivariable testing these dialysates were not independently associated with SAF. Other factors than PD fluid AGE content appear more important in determining SAF.
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http://dx.doi.org/10.1111/nep.13510DOI Listing
August 2019

Addressing the burden of dialysis around the world: A summary of the roundtable discussion on dialysis economics at the First International Congress of Chinese Nephrologists 2015.

Nephrology (Carlton) 2017 Dec;22 Suppl 4:3-8

Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.

To address the issue of heavy dialysis burden due to the rising prevalence of end-stage renal disease around the world, a roundtable discussion on the sustainability of managing dialysis burden around the world was held in Hong Kong during the First International Congress of Chinese Nephrologists in December 2015. The roundtable discussion was attended by experts from Hong Kong, China, Canada, England, Malaysia, Singapore, Taiwan and United States. Potential solutions to cope with the heavy burden on dialysis include the prevention and retardation of the progression of CKD; wider use of home-based dialysis therapy, particularly PD; promotion of kidney transplantation; and the use of renal palliative care service.
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http://dx.doi.org/10.1111/nep.13143DOI Listing
December 2017

Renal Association Clinical Practice Guideline on peritoneal dialysis in adults and children.

BMC Nephrol 2017 Nov 16;18(1):333. Epub 2017 Nov 16.

Patient Representative, c/o The Renal Association, Bristol, UK.

These guidelines cover all aspects of the care of patients who are treated with peritoneal dialysis. This includes equipment and resources, preparation for peritoneal dialysis, and adequacy of dialysis (both in terms of removing waste products and fluid), preventing and treating infections. There is also a section on diagnosis and treatment of encapsulating peritoneal sclerosis, a rare but serious complication of peritoneal dialysis where fibrotic (scar) tissue forms around the intestine. The guidelines include recommendations for infants and children, for whom peritoneal dialysis is recommended over haemodialysis.Immediately after the introduction there is a statement of all the recommendations. These recommendations are written in a language that we think should be understandable by many patients, relatives, carers and other interested people. Consequently we have not reworded or restated them in this lay summary. They are graded 1 or 2 depending on the strength of the recommendation by the authors, and A-D depending on the quality of the evidence that the recommendation is based on.
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http://dx.doi.org/10.1186/s12882-017-0687-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5691857PMC
November 2017

Comparison of Change in Peritoneal Function in Patients on Continuous Ambulatory PD vs Automated PD.

Perit Dial Int 2017 Nov-Dec;37(6):627-632. Epub 2017 Sep 28.

Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK.

Background: Patients on automated peritoneal dialysis (APD) may have greater exposure to glucose in the PD fluid than those on continuous ambulatory PD (CAPD). If this causes long-term damage to the peritoneal membrane, it will have implications for a patient's choice of modality.

Methods: Membrane function of long-term APD or CAPD patients was followed prospectively. The data were collected from electronic patient records in our unit from 2000 to 2014. The rate of change in membrane transport status (D/Pcr) and ultrafiltration (UF) for each patient was calculated using the least square regression line equation.

Results: We identified 106 APD and 123 CAPD patients who had a mean of 8.4 peritoneal equilibration test (PET) over 5.6 years. No differences were found in the rate of changes in D/Pcr or UF. Baseline solute clearance (Kt/V) was lower in APD patients (1.66 vs 1.76, = 0.04). However, APD patients experienced incremental changes to dialysis prescription that resulted in a greater increase in Kt/V compared with CAPD patients.

Conclusion: This is the largest study comparing the long-term effect of APD vs CAPD prescriptions. Despite more glucose being prescribed, there were no differences in the evolution of peritoneal membrane transport characteristics. The lower baseline Kt/V of APD patients might be explained by our aggressive use of incremental APD (tidal with dry day). Despite greater glucose prescriptions, initiating patients on APD based on patient preference appears to be safe for the long-term integrity of the peritoneal membrane.
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http://dx.doi.org/10.3747/pdi.2016.00101DOI Listing
July 2018

Comparison of equations of resting and total energy expenditure in peritoneal dialysis patients using body composition measurements determined by multi-frequency bioimpedance.

Clin Nutr 2018 04 17;37(2):646-650. Epub 2017 Feb 17.

UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK. Electronic address:

Background & Aims: Waste products of metabolism accumulate in patients with kidney failure and it has been proposed that the amount of dialysis treatment patients require be adjusted for energy expenditure. This requires validation of methods to estimate energy expenditure in dialysis patients.

Methods: We compared values of resting energy expenditure (REE) estimated in peritoneal dialysis (PD) patients using a selection of available equations with estimates derived using a novel equation recently validated in chronic kidney disease patients (CKD equation). We also determined the relationship of these estimates of REE and of total energy expenditure (TEE - which is REE plus physical activity associated energy expenditure (PAEE) estimated using the Recent Physical Activity Questionnaire) - to bioimpedance-derived parameters of body composition.

Results: We studied 118 adult PD patients; 75 male (63.6%), 33 diabetic (28.5%), Caucasoid (42.4%), mean age 59.3 ± 18.2 years and weight 73.1 ± 16.6 kg. REE with the CKD equation was 1532 ± 237 kcal/day, which was more than that for Mifflin-St. Joer 1425 ± 254, Harris-Benedict 1489 ± 267, Katch-McArdle 1492 ± 243, but less than Cunningham 1648 ± 248 kcal/day. Bland Altman mean bias ranged from -107 to 111 kcal/day. TEE was 1924 (1700-2262) kcal/day, and on multi-variate analysis was associated with appendicular muscle mass and nitrogen appearance rate (β 34.3, p < 0.001 and β 5.6, p = 0.002, respectively).

Conclusion: With reference to the CKD equation, the majority of standard equations underestimate REE in PD patients. Whereas the Cunningham equation overestimates REE. TEE was associated with appendicular muscle mass and estimated dietary protein intake.
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http://dx.doi.org/10.1016/j.clnu.2017.02.007DOI Listing
April 2018

Encapsulating Peritoneal Sclerosis.

Semin Nephrol 2017 01;37(1):93-102

Department of Nephrology and Hypertension, Fukushima Medical University School of Medicine, Fukushima, Japan.

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis. In this review, we describe the clinical picture and histologic changes to the peritoneal membrane that are associated with EPS and provide an update on current diagnosis and management. We also discuss the recent studies that have suggested that the use of more biocompatible solutions containing lower concentrations of glucose degradation product that often are pH neutral in combination with a change in clinical practice (reducing glucose exposure and monitoring peritoneal membrane function) might ameliorate peritoneal degeneration, reduce the incidence of EPS, and minimize the severity of the disease.
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http://dx.doi.org/10.1016/j.semnephrol.2016.10.010DOI Listing
January 2017

Peritoneal dialysis in patients with failed kidney transplant: Single centre experience.

Nephrology (Carlton) 2018 Feb;23(2):162-168

Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK.

Aim: To determine if patients with failing kidney transplants who opt to have peritoneal dialysis (PD) have poor short-term PD technique survival and increased rates of peritonitis.

Methods: We performed a retrospective analysis comparing 50 consecutive patients starting PD after a failed kidney transplant to 93 incident patients starting PD (matching for age, gender, diabetes causing renal failure, ethnicity and year of starting PD).

Results: The mean follow-up period was 26 months. PD technique survival was lower for the post-transplant cohort. However, this did not appear to be related to PD peritonitis risk; infection rate was lower in the post-transplant group albeit not statistically significant (1 in 23.6 patient months vs 1 in 22.5 patient months). There were no differences in the proportion of Gram positive: Gran negative: Culture Negative infections. The only fungal peritonitis occurred in a Control patient. Results of baseline Peritoneal Equilibration Tests were not different; D/Pcr was 0.69 for post-TP versus 0.64 for Control (P = ns), and net UF was 250 mL for post-TP versus 310 mL for Control (P = ns). PET results after 12 months were also similar.

Conclusion: Our study found a small but significantly higher rate of PD technique failure in the post-transplant cohort, but this did not appear to be related to peritonitis rates or peritoneal membrane function. Further studies are required to explore reasons for PD technique failure in patients who have had kidney transplant, but our study supports the use of PD in selected patient from this cohort.
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http://dx.doi.org/10.1111/nep.12951DOI Listing
February 2018

Could metformin be used in patients with diabetes and advanced chronic kidney disease?

Diabetes Obes Metab 2017 02 9;19(2):156-161. Epub 2016 Nov 9.

Department of Nephrology, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK.

Diabetes is an important cause of end stage renal failure worldwide. As renal impairment progresses, managing hyperglycaemia can prove increasingly challenging, as many medications are contra-indicated in moderate to severe renal impairment. Whilst evidence for tight glycaemic control reducing progression to renal failure in patients with established renal disease is limited, poor glycaemic control is not desirable, and is likely to lead to progressive complications. Metformin is a first-line therapy in patients with Type 2 diabetes, as it appears to be effective in reducing diabetes related end points and mortality in overweight patients. Cessation of metformin in patients with progressive renal disease may not only lead to deterioration in glucose control, but also to loss of protection from cardiovascular disease in a cohort of patients at particularly high risk. We advocate the need for further study to determine the role of metformin in patients with severe renal disease (chronic kidney disease stage 4-5), as well as patients on dialysis, or pre-/peri-renal transplantation. We explore possible roles of metformin in these circumstances, and suggest potential key areas for further study.
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http://dx.doi.org/10.1111/dom.12799DOI Listing
February 2017

A single weekly Kt/Vurea target for peritoneal dialysis patients does not provide an equal dialysis dose for all.

Kidney Int 2016 12 18;90(6):1342-1347. Epub 2016 Sep 18.

UCL Centre for Nephrology, Royal Free Hospital, University College London Medical School, London, United Kingdom. Electronic address:

Dialysis adequacy is traditionally based on urea clearance, adjusted for total body volume (Kt/Vurea), and clinical guidelines recommend a Kt/Vurea target for peritoneal dialysis. We wished to determine whether adjusting dialysis dose by resting and total energy expenditure would alter the delivered dialysis dose. The resting and total energy expenditures were determined by equations based on doubly labeled isotopic water studies and adjusted Kturea for resting energy expenditure and total energy expenditure in 148 peritoneal dialysis patients (mean age, 60.6 years; 97 male [65.5%]; 54 diabetic [36.5%]). The mean resting energy expenditure was 1534 kcal/d, and the total energy expenditure was 1974 kcal/day. Using a weekly target Kt/V of 1.7, Kt was calculated using V measured by bioimpedance and the significantly associated (r = 0.67) Watson equation for total body water. Adjusting Kt for resting energy expenditure showed a reduced delivered dialysis dose (ml/kcal per day) for women versus men (5.5 vs. 6.2), age under versus over 65 years (5.6 vs. 6.4), weight <65 versus >80 kg (5.8 vs. 6.1), low versus high comorbidity (5.9 vs. 6.2), all of which were significant. Adjusting for the total energy expenditure showed significantly reduced dosing for those employed versus not employed (4.3 vs. 4.8), a low versus high frailty score (4.5 vs. 5.0) and nondiabetic versus diabetic (4.6 vs. 4.9). Thus, the current paradigm for a single target Kt/Vurea for all peritoneal dialysis patients does not take into account energy expenditure and metabolic rate and may lead to lowered dialysis delivery for the younger, more active female patient.
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http://dx.doi.org/10.1016/j.kint.2016.07.027DOI Listing
December 2016

Is overhydration in peritoneal dialysis patients associated with cardiac mortality that might be reversible?

World J Nephrol 2016 Sep;5(5):448-54

Elizabeth Oei, Klara Paudel, Stanley L Fan, Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London E1 1BB, United Kingdom.

Aim: To study the relationship between overhydration (OH) in peritoneal dialysis (PD) patients and cardiac mortality.

Methods: OH, as measured by body composition monitor (BCM), is associated with increased mortality in dialysis patients. BCM has been used to guide treatment on the assumption that correcting OH will improve cardiac morbidity and mortality although data demonstrating causality that is reversible is limited. We wished to determine if OH in PD patients predicted cardiac mortality, and if there was a correlation between OH and cardiac troponin-T (cTnT) levels. Finally, we wished to determine if improving OH values would lead to a decrement in cTnT. All prevalent PD patients over the study period of 57 mo who had contemporaneous BCM and cTnT measurements were followed irrespective of transplantation or PD technique failure. We also studied a cohort of patients with who had severe OH (> +2L). The Fresenius Body Composition Monitor was used to obtain hydration parameters. cTnT levels were done as part of routine clinical care. Data was analysed using SPSS version 20.0.

Results: There were 48 deaths in the 336 patients. The patients that died from cardiac or non-cardiac causes were similar with respect to their age, incidence of diabetes mellitus, gender, ethnicity and cause of renal failure. However, the patients with cardiac causes of death had significantly shorter dialysis vintage (10.3 mo vs 37.0 mo, P < 0.0001) and were significantly more overhydrated by BCM measurement (2.95 L vs 1.35 L, P < 0.05). The mean (standard error of the means) hydration status of the 336 patients was +1.15 (0.12) L and the median [interquartile range (IQR)] cTnT level was 43.5 (20-90) ng/L. The cTnT results were not normally distributed and were therefore transformed logarithmically. There was a statistically significant correlation between Log (cTnT) with the OH value (Spearman r value 0.425, P < 0.0001). We identified a sub-group of patients that were severely overhydrated; median (IQR) hydration at baseline was +2.7 (2.3 to 3.7) L. They were followed up for a minimum of 6 mo. Reduction in OH values in these patients over 6 mo correlated with lowering of cTnT levels (Spearman r value 0.29, P < 0.02).

Conclusion: Patients that were overhydrated had higher cTnT, and had deaths that were more likely to be cardiac related. Reduction in OH correlated with lowering of cTnT.
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http://dx.doi.org/10.5527/wjn.v5.i5.448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5011251PMC
September 2016

Use of Continuous Glucose Monitoring in Patients with Diabetes Mellitus on Peritoneal Dialysis: Correlation with Glycated Hemoglobin and Detection of High Incidence of Unaware Hypoglycemia.

Blood Purif 2016 20;41(1-3):18-24. Epub 2015 Oct 20.

Joint International Society of Nephrology and Kidney Research UK Fellow at the Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK.

Introduction: Glycated hemoglobin is used to assess diabetic control although its accuracy in dialysis has been questioned. How does it compare to the Continuous Glucose Monitoring System (CGMS) in peritoneal dialysis (PD) patients?

Methods: We conducted a retrospective analysis of 60 insulin-treated diabetic patients on PD. We determined the mean interstitial glucose concentration and the proportion of patients with hypoglycemia (<4 mmol/l) or hyperglycemia (>11 mmol/l).

Results: The correlation between HbA1c and glucose was 0.48, p < 0.0001. Three of 15 patients with HbA1c >75 mmol/mol experienced significant hypoglycemia (14-144 min per day). The patients with frequent episodes of hypoglycemia could not be differentiated from those with frequent hyperglycemia by demographics or PD prescription.

Conclusion: HbA1c and average glucose levels measured by the CGMS are only weakly correlated. On its own, HbA1c as an indicator of glycemic control in patients with diabetes on PD appears inadequate. We suggest that the CGMS technology should be more widely adopted.
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http://dx.doi.org/10.1159/000439242DOI Listing
December 2016

Optimizing Peritoneal Dialysis Catheter Placement by Lateral Abdomen X-Ray.

Perit Dial Int 2015 Dec;35(7):760-2

Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK

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http://dx.doi.org/10.3747/pdi.2014.00263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4690634PMC
December 2015

Does Loss of Residual Renal Function Lead to Increased Volume Overload and Hypertension in Peritoneal Dialysis Patients?

Perit Dial Int 2015 Dec;35(7):753-5

UCL Center for Nephrology, Royal Free Hospital, University College London Medical School, London, UK

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http://dx.doi.org/10.3747/pdi.2014.00147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4690631PMC
December 2015

Peritoneal Dialysis Adequacy in Elderly Patients.

Perit Dial Int 2015 Nov;35(6):635-9

Barts Health NHS Trust - Department of Renal Medicine and Transplantation London, United Kingdom

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http://dx.doi.org/10.3747/pdi.2014.00336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4689465PMC
November 2015

The importance of overhydration in determining peritoneal dialysis technique failure and patient survival in anuric patients.

Int J Artif Organs 2015 Nov 7;38(11):575-9. Epub 2015 Dec 7.

UCL Centre for Nephrology, Royal Free Hospital, University College London Medical School, London - UK.

Purpose: Loss of residual renal function (RRF) is associated with an increased risk for peritoneal dialysis (PD) technique failure and patient death. We wished to determine which factors were associated with PD technique failure and patient mortality once urine output had fallen to <100 mL/day.

Methods: We followed 183 PD patients who lost RRF and who had measurements taken at that time of PD small solute clearances, ultrafiltration volume, PD transport status and multiple frequency bioelectrical impedance assessments (MFBIA) of extracellular water (ECW).

Results:

Results: 119 (65%) patients had PD technique failure or died during a median follow-up of 20.8 (10.5-36) months. This group had more men (58.8% vs. 31.9%, p = 0.011), and were older 57.9 ± 14.7 vs. 49.3 years (p = 0.002). These patients had a higher median C-reactive protein 5.5 [4.8-8.2] vs (5.0 [2-6] p = 0.013), and greater comorbidity (Davies grade 1 [0-1] vs. 0[0-1], p<0.001, and a higher ratio of ECW/TBW (0.45 ± 0.07 vs 0.42 ± 0.04, p<0.001). There were no differences in icodextrin usage, small solute clearance or ultrafiltration volumes. On multivariate Cox regression, ECW excess was significantly associated with PD technique failure and patient survival (β 1.09, p<0.001 and β1.17, p = 0.005), respectively.

Conclusions: Loss of urine output requires PD to provide both adequate solute clearances and volume control. We found that PD technique failure and patient death were associated with ECW excess. Prospective interventional studies are required to determine whether correction of volume status improves PD patient outcomes.
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http://dx.doi.org/10.5301/ijao.5000446DOI Listing
November 2015

Hydration status measured by BCM: A potential modifiable risk factor for peritonitis in patients on peritoneal dialysis.

Nephrology (Carlton) 2016 May;21(5):404-9

Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK.

Aim: Peritoneal dialysis peritonitis and fluid overhydration (OH) are frequent problems in peritoneal dialysis. The latter can cause gut wall oedema or be associated with malnutrition. Both may lead to increased peritonitis risk. We wished to determine if OH is an independent risk factor for peritonitis (caused by enteric organisms).

Methods: Retrospectively study of patients with >2 bioimpedance assessments (Body Composition Monitor). We compared peritonitis rates of patients with above or below the median time-averaged hydration parameter (OH/extracellular water, OH/ECW). Multivariate analysis was performed to determine independent risk factors for peritonitis by enteric organism.

Results: We studied 580 patients. Peritonitis was experienced by 28% patients (followed up for an average of 17 months). The overall peritonitis rate was 1:34 patient months. Patients with low OH/ECW values had significantly lower rates of peritonitis from enteric organisms than overhydrated patients (incident rate ratio 1.53, 95% confidence interval 1.38-1.70, P < 0.001). Hydration remained an independent predictor of peritonitis from enteric organisms when multivariate model included demographic parameters (odds ratio for a 1% increment of OH/ECW was 1.05; 95% confidence interval 1.01-1.10, P < 0.02). However, including biochemical parameters of malnutrition reduced the predictive power of overhydration.

Conclusion: We found an association between overhydration and increased rates of peritonitis. While this may partly be due to the high co-morbidity of patients (advanced age and diabetes), on multivariate analysis, only inclusion of nutritional parameters reduced this association. It remains to be determined if overhydration will prove to be a modifiable risk factor for peritonitis or whether malnutrition will prove to be more important.
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http://dx.doi.org/10.1111/nep.12622DOI Listing
May 2016
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