E-learning modules for Integrated Virtual Learning



    Posts : 31
    Join date : 2009-06-19
    Age : 32


    Post  gillegarda/joanalynbalino on Sun 05 Jul 2009, 11:38 pm

    By: D2- Gil Legarda and Joanalyn Balino

    Carol A. Pollock

    Pollock made an analysis on the different researches and guidelines about the impact of anemia management in renal disease on clinical outcome. She summarized the different clinical practice guidelines on anemia management for renal disease. All the guidelines from different countries and regions uniformly recommend: (1) The minimum target hemoglobin(Hb) level is 11 g/DL; (2) Hb should not exceed 12 g/dL for those who have proven or possible cardiovascular disease; (3) Predialysis Hb levels should not exceed 14 g/ dL; (4) For hemodialysis population, Iron supplemattion is best administered intravenously; (5) serum ferritin > 100 g/L and a transferrin saturation of >20% should be the value to describe that iron storage is complete or sufficient. There were only low possibilities to assess the implementation of these guidelines. There were only few studies that provide evidences that a higher Hb confers a survival advantage in patients with chronic kidney impairment in patients.

    Pollock cited different studies that discusses that higher Hb offer a survival advantage in patients with chronic kidney impairment These studies were: McDonald S, Russ G et al.(2003): approximately 16% of hemodialysis patients have Hb above 13 g/dL and if Hb between 11.0 and 11.9 g/dL there is a lower risk of mortality compared to Hb of 12 –14 g/dL. The mortality is similar with peritoneal dialysis patients with Hb between 10.5 and 12 g/dL and those who have Hb greater than 12 g/dL. Those with Hb > 12 g/dL survival is improved. Besarab et al.(1998) concluded that there is relatively strong evidence that a higher Hb target may increase mortality in patients with cardiovascular disease and perhaps in patients with diabetes mellitus. Ofsthun N. et al (2003) made an observational and longitudinal studies and suggested that there is no increased risk of death in patients on hemodialysis whose Hb is above 12 g/dL and a survival benefit occurs if Hb is between 12 and 13 g/dL and reduction in the number of hospitalizations and the length of stay in patients. Pisoni RL. et al. (2004) made an observational studies of hemodialysis patients (Hb above 12 g/dL) for each increase in Hb of 1 g/dL, an overall relative risk reduction in mortality of 5% was achieved But there is no significant reduction in hospitalization rate observed in patients whom Hb was above
    12 g/dL.

    The clinical factors of achieving Hb targets include:(1) Variability in hemoglobin Hb levels in individual patients;(2) thresholds for altering iron therapy and epoetin doses; (3) and variability in response to treatments aimed at improving Hb levels. When Hb concentrations are greater than 10 g/dL, there are benefits in quality of life, physical performance, and cognitive function. To optimize Hb concentrations and improve clinical outcomes, increasing iron supplementation and optimizing urea clearance are suggested in addition to prescribing epoetin.

    ANEMIA ON CLINICAL OUTCOME. Peritoneal Dialysis International, Vol. 25, Supplement 3. Retrieved July 3, 2009 from http://www.pdiconnect.com/cgi/reprint/25/Suppl_3/S99?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&minscore=5000&resourcetype=HWCIT

    5th POSTING- Peritoneal Dialysis: MORTALITY
    By: Dyad2: Gil Legarda / Joanalyn Balino

    Effects of Increased Peritoneal Clearances on Mortality Rates in Peritoneal Dialysis: ADEMEX, a Prospective, Randomized, Controlled Trial

    Ramo’ N Paniagua et al. studies about the effects of increased peritoneal clearances on death dates in PD among patients with ESRD who were being treated with continous ambulatory peritoneal dialysis or CAPD. This study was carried out in a randomized controlled, clinical trial which the rsearchers called it adequacy of peritoneal dialysis in Mexico (ADAMEX). There were 965 subjects from 24 dialysis centers. These subjects were assigned to intervention group in a one is to one ratio through central randomization center. Subjects in control group continued with their existing peritoneal dialysis prescriptions. Inclusion citeria was subjects should undegone at least 3 months of peritoneal dialysis, ages between 18 to 70 years old, with prescription of four daily exchange of 2 liters and exhibited 60 L/week per set creatinine clearance. Patiebnts unable to give informed consent , with seropositive Hep B or HIV, receiving immunosuppressant medication, had malignancies, abdominal hernias or heart failure, had experienced a peritonitis episode for 1 month before enrolment of the study were excluded. The settings of the study where in 24 dialysis cneters in 14 Mexican cities. 21 of the dialysis centers were part of the Instituto Mexicano del Seguro Social, and 2 were part of the Instituti de Seguridad yServicios Sociales de los Trabajadores. The remaining center waas the Instituto Nacional de Ciencias Me dicas y Nutricio n Savador Zubira n in Mexico City. There were Clinical History assessment, Physical assessment and laboratory tests as baseline information and would served as an instrument for analysing data. The all in all analysis of patient survival was performed by the use of life-table techniques with comparisons made on the basis of the logic rank test. The assessment of the effectivity of the intervention suggested by the researchers served as the measures of outcomes. The limitation this study was the subjects were PD patients only and the Hemodialysis patients were not included also ESRD is the only disease included how about the kidney diseases prior to ESRD.

    In terms of the demographic characteristics the both experimental and control groups were similar also in prevalence of coexisting conditions, causes of renal disease, peritoneal clearances residual renal function, peritoneal clearances before the intervention, multiple indicators of nutritional status and hematrocrit values. Peritoneal creatinine clearance and urea clearance were remained in the control group while in the intervention group peritoneal kt/V values and pcrCL increased and remained separated from the values for the entire duration of the study. Mortality rates were similar in the result for the both groups even if there was an adjustment for the factors associated with the survival.

    This study provides factors which can affect the mortality in both different therapy or types of dialysis. It shows that small solute clearances can has an effect regarding the survival of patients whwnever patients were grouped according to variety of factors such as age, diabetes mellitus, serum albumin levels, normalized protein equivalent of total nitrogen appearance and anuria. There are some lockage in this study such as practices which may be added in the factors also the subcategorizing the patients according to age group if which patients can have an increased creatinine clearance or risk for death.

    Paniagua R. (2002). Effects of Increased Peritoneal Clearances on Mortality Rates in Peritoneal Dialysis: ADEMEX, a Prospective, Randomized, Controlled Trial. Journal of the American Society of Nephrology Vol. 13 pages 1307–1320.

    Last edited by gillegarda/joanalynbalino on Tue 07 Jul 2009, 2:13 am; edited 1 time in total

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    5TH POSTING: ---------- FOLLOW-UP GUIDELINES and MORTALITY Empty prognosis by YuanShuHui & YangChunHua

    Post  YangChunHua on Mon 06 Jul 2009, 12:57 pm

    Important differentiation of factors that predict outcome in peritoneal dialysis patients with different degrees of residual renal function

    Nephrology Dialysis Transplantation 2005 20(2):396-403;

    Angela Yee-Moon Wang1, Jean Woo2, Mei Wang1, Mandy Man-Mei Sea2, John E. Sanderson1, Siu-Fai Lui1 and Philip Kam-Tao Li1

    Residual renal function (RRF) contributes significantly to the total solute clearance in peritoneal dialysis (PD) patients and is well recognized as an important factor influencing mortality, nutrition status and quality of life in chronic PD patients. However, an inevitable decline in RRF is observed with time on dialysis, and PD clearance is usually increased to compensate for the loss in RRF.

    RRF is an important predictor of outcome in peritoneal dialysis patients. Whether results from survival studies in dialysis patients with RRF can also be extrapolated to anuric patients remains uncertain. In this observational study, we examined the characteristics of PD patients with a residual glomerular filtration rate (GFR) 1 ml/min per 1.73 m2 vs those with complete anuria and differentiated factors that predict outcome in the two groups of patients.
    Two hundred and forty-six continuous ambulatory peritoneal dialysis (CAPD) patients (39% being completely anuric) were recruited from a single regional dialysis centre. Assessments of haemodynamic, echocardiographic, nutritional and biochemical parameters and indices of dialysis adequacy were done at study baseline and were related to outcomes.
    During the prospective follow-up of 30.8±13.8 (mean±SD) months, 28.0% of patients with residual GFR 1 ml/min per 1.73 m2 vs 50.5% of anuric patients had died (P = 0.005). The overall 2 year patient survival was 89.7 and 65.0% for patients with GFR 1 ml/min per 1.73 m2 and anuric patients, respectively (P = 0.0012). Compared with patients with GFR 1 ml/min per 1.73 m2, anuric patients were dialysed for longer (P<0.001), were more anaemic (P<0.005), and had higher calcium–phosphorus product (P<0.01), higher C-reactive protein (P<0.001), lower serum albumin (P<0.05), greater prevalence of malnutrition according to subjective global assessment (P<0.05) and more severe cardiac hypertrophy (P<0.001) at baseline. Using multivariable Cox regression analysis, serum albumin, left ventricular mass index and residual GFR were significant factors associated with mortality in patients with GFR 1 ml/min per 1.73 m2, while increasing age, atherosclerotic vascular disease and higher C-reactive protein were associated with greater mortality in anuric PD patients.
    Our study demonstrates more adverse cardiovascular, inflammatory, nutritional and metabolic profiles as well as higher mortality in anuric PD patients. Furthermore, factors associated with mortality are also not equivalent for PD patients with and without RRF, suggesting that patients with and without RRF are qualitatively different.
    1. Rocco M, Soucie JM, Pastan S, McClellan WM. Peritoneal dialysis adequacy and risk of death. Kidney Int 2000; 58: 446–457
    2. Wang AY, Sea MM, Ip R et al. Independent effects of residual renal function and dialysis adequacy on actual dietary protein, calorie and other nutrients intake in patients on continuous ambulatory peritoneal dialysis. J Am Soc Nephrol 2001; 12: 2450–2457
    3. Bargman JM, Thorpe KE, Churchill DN, for the CANUSA Peritoneal Dialysis Study Group. Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol 2001; 12: 2158–2162
    .Paniagua R, Amato D, Voneshi E et al. for the Mexican Collaborative Study Group. Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized, controlled trial. J Am Soc Nephrol 2002; 13: 1307–1320
    Szeto CC, Wong TY, Chow KM et al. Impact of dialysis adequacy on the mortality and morbidity of anuric Chinese patients receiving continuous ambulatory peritoneal dialysis. J Am Soc Nephrol 2001; 12: 355–360
    Bhaskaran S, Schaubel DE, Jassal SV et al. The effect of small solute clearance on survival of anuric peritoneal dialysis patients. Perit Dial Int 2000; 20: 181–187
    7. Lo WK, Ho YW, Li CS et al. Effect of Kt/V on survival and clinical outcome in CAPD patients in a randomized prospective study. Kidney Int 2003; 64: 649–656
    8.Wang AY, Woo J, Lam CK et al. Is a single time-point C-reactive protein predictive of outcome in peritoneal dialysis patients? J Am Soc Nephrol 2003; 14: 1871–1879
    9.Panichi V, Migliori M, De Pietro S et al. C-reactive protein and interleukin levels are related to renal function in pre-dialytic chronic renal failure. Nephron 2002; 91: 594–600
    10. Van Biesen W, Vanholder R, Lameire N. The role of peritoneal dialysis as the first-line renal replacement modality. Perit Dial Int 2000; 20: 375–383

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    Post  alkhaloidz on Mon 06 Jul 2009, 11:52 pm

    DYAD 4

    Timing, causes, predictors and prognosis of switching from peritoneal dialysis to hemodialysis: a prospective study

    The use of peritoneal dialysis (PD) has declined in the United States over the past decade and technique failure is also reportedly higher in PD compared to hemodialysis (HD), but there are little data in the United States addressing the factors and outcomes associated with switching modalities from PD to HD. In a prospective cohort study of 262 PD patients enrolled from 28 peritoneal dialysis clinics in 13 U.S. states, we examined potential predictors of switching from PD to HD (including demographics, clinical factors, and laboratory values) and the association of switching with mortality. Cox proportional hazards regression was used to assess relative hazards (RH) of switching and of mortality in PD patients who switched to HD.

    Among 262 PD patients, 24.8% switched to HD; with more than 70% switching within the first 2 years. Infectious peritonitis was the leading cause of switching. Patients of black race and with higher body mass index were significantly more likely to switch from PD to HD, RH (95% CI) of 5.01 (1.15–21.Cool for black versus white and 1.09 (1.03–1.16) per 1 kg/m2 increase in BMI, respectively. There was no difference in survival between switchers and non-switchers, RH (95% CI) of 0.89 (0.41–1.93).

    Switching from PD to HD occurs early and the rate is high, threatening long-term viability of PD programs. Several patient characteristics were associated with the risk of switching. However, there was no survival difference between switchers and non-switchers, reassuring providers and patients that PD technique failure is not necessarily associated with poor prognosis. Moreover, we were able to identify important independent risk factors for switching from PD to HD (BMI and black race). In this context, more studies are definitely needed to better understand why black PD patients were more likely to switch to HD over time. Finally, our findings of no survival difference between PD switchers and non-switchers should be reassuring to providers and patients that PD technique failure is not necessarily associated with poor prognosis, but a timely transfer in setting of complications remains important.

    REFERENCE: Jaar B. Timing, causes, predictors and prognosis of switching from peritoneal dialysis to hemodialysis: a prospective study. PMC. February 2009

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    5TH POSTING: ---------- FOLLOW-UP GUIDELINES and MORTALITY Empty Response: Follow up Peritoneal Dialysis

    Post  VonDeneb_Vitto on Tue 07 Jul 2009, 1:46 am

    Dyad 3
    Byron Webb A. Romero
    Von Deneb H. Vitto
    Raymond C. Ursal

    Response: Follow up Peritoneal Dialysis

    ESRD patients who are on either PD or HD dies mainly because of co-morbidities of their condition, which mainly is of cardiovascular origin, infective origins also contribute to development of complications (Arulkumara, 2007). PD patients must be followed up closely and be monitored on their renal and cardiovascular functions, being certain on their compliance to cardiovascular medications that plays an important role in the prevention of the development and progression of co-morbidities comprising about 50% of all deaths. The study conducted was about ESRD patients undergoing dialysis that are admitted to the Intensive Care Unit (ICU). The study concerns prognosis of PD patients after being admitted to the ICU. It looked at other research studies but do not have actual clinical monitoring of patients, which may be a limitation of the study.


    Arulkumaran, N., Eastwood, J., and Banerjee, D. (2007). Haemodialysis and peritoneal dialysis patients admitted to intensive care units. Crit Care (2007) 11(3): 133. Retreived July 6, 2009 from http://ukpmc.ac.uk/articlerender.cgi?tool=pmcentrez&accid=pmcA2206406

    5TH POSTING: ---------- FOLLOW-UP GUIDELINES and MORTALITY Empty Prognosis of ESRD (Peritoneal Dialysis)

    Post  nancelle on Wed 08 Jul 2009, 1:48 am

    DYAD 1 : Nanncelle Dumlao/ Rodel Perez
    Prognosis Peritoneal Dialysis

    Peritoneal Dialysis and Epithelial-to-Mesenchymal Transition of Mesothelial Cells

    By: Yáñez-Mó, M, et al, 2003

    This is a study to determine whether continuous ambulatory peritoneal (CAPD), one of the treatment modalities of ESRD, causes mesothelial cells lining the peritoneum to undergo transdifferentiation or transformation from epithelial to mesenchymal cells which in the long run results to failure in ultrafiltration by the peritoneum. In CAPD, the peritoneum is used as a filter to remove wastes from the body that are normally excreted by the kidneys. The peritoneal membrane is lined with a single layer of mesothelial cells that acts as permeable barrier and secrets substances that allow peritoneal permeability and provide local host defense. However, the prolonged exposure to hyperglycemic, hyperosmotic, and acidic solutions used in dialysis causes irritation or inflammation of the lining which denudes the mesothelial layer and consequently causes fibrosis. This structural alterations (which may be hastened by recurrent peritonitis) leads to the decrease in the peritoneum’s ability for ultrafiltration during peritoneal dialysis and this affects 20 percent of CAPD patients. This study was conducted to understand the mechanism of this process of mesothelial cells transformation. The study included the segregation of mesothelial cells from dialysis fluids from 54 clinically stable CAPD patients through the process of centrifugation. Changes in the cells’ characteristics were identified using the following methods cytometry, confocal immunofluorescence, Western blotting, and reverse-transcriptase polymerase chain reaction.

    The results of the study confirmed morphologic changes were observed from those patients undergoing CAPD and these changes were associated to the duration of CAPD and whether the patient had history of peritonitis or hemoperitoneum. The mesothelial cells were transformed from an epithelial phenotype to a mesenchymal phenotype which were confirmed using immunohistochemical analysis (e.g. cytokeratins, E-cadherin, 2 integrin) on the specimens obtained from the peritoneum. Likewise, it was found out that wound repair and profibrotic and inflammatory cytokines are factors that causes transdifferentiation of the lining of peritoneum which subsequently lead to the failure on ultrafiltration in peritoneal dialysis.

    In summary, it has been proven that prolonged continuous peritoneal dialysis will eventually result to deterioration in the functioning of the peritoneum as a permeable barrier that cleans the body of accumulated wastes due to the morphological changes in the mesothelial cells lining the peritoneum. This valuable information may be utilized by other researchers to develop new dialysis solutions which protect the mesothelial lining of the peritoneum from being damaged. If prolonged CAPD results to formation of fibrosis in the peritoneum which causes failure in the ultrafiltration, then the patients’ health status will deteriorate due to the accumulation of waste products. The prognosis of these patients will be poor as a result of ineffective dialysis. They will be forced to shift to hemodialysis which is a more time - consuming and limiting treatment modality.

    Yáñez-Mó, M., Lara-Pezzi,E., Selgas,R., et al. Peritoneal Dialysis and Epithelial-to-Mesenchymal Transition of Mesothelial Cells. ( 2003) New England Journal of Medicine, volume 348:403-413.

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    5TH POSTING: ---------- FOLLOW-UP GUIDELINES and MORTALITY Empty peritoneal dialysis diagnostics

    Post  guomanman on Wed 08 Jul 2009, 9:22 am

    Dyad 6 guomanman and chenya

    ScienceDaily (Oct. 17, 2007) — Scientists at Robarts Research Institute and The University of Western Ontario expect that patients undergoing peritoneal dialysis may soon be able to worry less about the risks of infection and lessen their hospital stays.

    Peritoneal dialysis, which involves placing a tube into the peritoneal cavity, allows people who have suffered from kidney failure to carry on a relatively normal life; however, complications include high incidence of infection of the abdominal cavity, known as peritonitis, which most patients experience every year or so.

    Led by Joaquin Madrenas, Robarts scientist and Canada Research Chair in Immunobiology at Western, the new study has looked at the molecule RIP2 (receptor-interacting protein 2) for clues over the past three years. Though the precise function of RIP2 is not yet known, scientists made the important finding that levels of the molecule increase during infection.

    More importantly, peritoneal dialysis patients with peritonitis who have high levels of RIP2 can be sent home and treated with antibiotics. If RIP2 levels do not go up, patients risk a protracted infection and should be admitted for closer monitoring and more intense treatment. This information can be used to address the need to admit patients to the hospital.

    “We currently have no objective indicator if peritonitis will be really bad, so we tend to try to guess how bad it is,” says Madrenas. “What we have found is that, by monitoring RIP2, we can predict the outcome of the infection in patients taking part in peritoneal dialysis.”

    By keeping patients out of hospitals, this discovery not only helps improve quality of life, but also reduces strain on the healthcare system.

    The team, which includes Madrenas’ PhD student Michelle McCully and a close collaboration with Dr. Peter Blake of the division of nephrology at Western, will now try to adapt the discovery to a clinical laboratory and hopefully develop a diagnostic test that can be conducted with a patient’s peritoneal fluid on a routine basis.

    Madrenas also wonders if there are other factors preventing RIP2 levels from increasing in some patients. “If we know what problem is preventing this increase, we could fix it and possibly prevent infections,” he says.
    byron webb romero
    byron webb romero

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    Post  byron webb romero on Wed 08 Jul 2009, 11:40 am

    Dyad Three (3)
    Byron Webb A. Romero
    Von Deneb H. Vitto
    Raymond C. Ursal


    Hutchison, Crowe, Stevens, Harrison and Lipkin (2007 [cited in Arulkumaran, Eastwood and Banerjee, 2007) reported a 10-year experience of dialysis patients admitted to intensive care units (ICUs) in the United Kingdom (excluding Scotland). Accordingly, improvements in the provision of facilities for dialysis patients and their rising expectations would likely lead to an increase in the number of critically ill dialysis patients presenting to the ICU. In this cohort study, it involved 3,420 dialysis patients out of a total of 276,731 ICU admissions between 1995 and 2004. In 2003, a dialysis program with 100 patients had an ICU bed requirement of 32 days or atleast about one month in a year. Considering this admission rate, one ICU bed will then support a population of about 1,200 dialysis patients. It is surprising however, that there was no increase over the 9 years despite the known increase of about 50% in the number of dialysis patients over the same period of time.

    This study by Hutchison and colleagues demonstrates an ICU mortality of 26% and an 'in-hospital' mortality of 45% in dialysis patients. These figures are encouraging when one considers that patients in the dialysis group were considerably sicker, with higher Acute Physiology and Chronic Health Evaluation II (APACHE) scores (24.7 versus 17.2) than other ICU admissions. The median length of stay in an ICU of the dialysis group was however very similar to that of the non-dialysis group (1.9 days versus 1.8 days). This 1.9 days length of stay is very much at the lower end of the range. It is also interesting to note that the dialysis group had both longer overall hospital stay and higher death rate after discharge from the ICU. These data would now suggest that the dialysis patients may be leaving the ICU too early, or that there may perhaps be a perception in ICUs that renal wards are better equipped than general wards to receive patients from ICU and patients may be transferred too early.

    Arulkumaran, N., Eastwood, J.B., & Banerjee, D. (2007). Haemodialysis and peritoneal dialysis patients admitted to intensive care units. Critical care. 2007; 11(3):133. Retrieved July 7, 2009, from http://ukpmc.ac.uk/articlerender.cgi?tool=pmcentrez&accid=pmcA2206406.

    Hutchison, C.A, Crowe, A.V., Stevens, P.E., Harrison, D.A., & Lipkin, G.W. (2007). Case mix, outcome and activity for admissions to intensive care units requiring chronic renal dialysis: a secondary analysis of the ICNRC Case Mix Program Database. Critical Care. 2007;11.

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