Objectives The aim of this study was to assess the prevalence of hernias before and after the start of continuous ambulatory peritoneal dialysis (CAPD) in patients with end-stage renal disease, and to evaluate the result of a proposed surgical treatment. Design Prospective observational study. Setting University hospital. Patients 122 patients who started CAPD from 1994 to 2000; 26 hernias were diagnosed in 21 (17.2%) patients. Main Outcome Measures Finding of hernias; morbidity associated with catheter insertion and hernia repair; recurrence of hernias. Results 19 hernias were detected in 15 patients (12.3%) before they began CAPD; only 7 hernias were observed while on CAPD. Umbilical (61.5%) and inguinal (26.9%) hernias were the most common. Multiple hernias were detected in 4 patients. Simultaneous repair of hernia and catheter insertion was performed in patients with preexisting hernias. Under local anesthesia, most patients were operated on with surgical techniques of tension-free hernioplasty using a polypropylene mesh. Only mild postoperative complications were recorded: 3 seromas and 1 hematoma. No fluid leakage was found in our series. There were no long-term complications (infection or recurrence) related to the mesh. Conclusions 73% of hernias in peritoneal dialysis patients occur before starting dialysis. Hernia problems in these high-risk patients can be safely solved using a careful technique with application of tension-free hernioplasty. Most may be repaired under local anesthesia with simultaneous catheter insertion.

Objective To compare the survival among patients with chronic kidney disease who had optimal starts of renal replacement therapy, dialysis or hemodialysis, with patients who had suboptimal starts. Methods A retrospective cohort consisting of >18 year-old patients who started renal replacement therapy, using peritoneal dialysis or hemodialysis, in any public hospital or associated center of the Andalusian Public Health System, between the 1 st of January of 2006 and the 15 th of March of 2017. The optimal start was defined when all the following criteria were met: a planned dialysis start, a minimum of six-month follow-up by a nephrologist, and a first dialysis method coinciding with the one registered at 90 days. The information was obtained from the registry of the Information System of the Transplant Autonomic Coordination of Andalusia. Results A total of 10,692 patients were studied. 4,377 (40.9%) of these patients died. A total of 4,937 patients (46.17%) achieved optimal starts of renal replacement therapy and showed higher survival rates (HR 0.669; 95% CI 0.628–0.712) in the multivariate analysis of Cox regression model. Conclusions Patients with an optimal start of renal replacement therapy have a greater survival than those who had a non-optimal start. Therefore, the necessary measures should be encouraged to increase the optimal start of the patient in dialysis.

BackgroundBaseline residual kidney function (RKF) and its rate of decline during follow-up are purported to be reliable outcome predictors of patients undergoing Peritoneal Dialysis (PD). The independent contribution of each of these factors has not been elucidated.MethodWe report a multicenter, longitudinal study of 493 patients incident on PD and satisfying two conditions: a glomerular filtration rate (GFR) ≥1 mL/minute and a daily diuresis ≥300 mL. The main variables were the GFR (mean of urea and creatinine clearances) at PD inception and the GFR rate of decline during follow-up. The main outcome variable was patient mortality. The secondary outcome variables were: PD technique failure and risk of peritoneal infection. The statistical analysis was based on a multivariate approach, placing an emphasis on the interactions between the two main study variables.Main ResultsBaseline GFR and its rate of decline performed well as independent predictors of both patient mortality and risk of peritoneal infection. These two main study variables maintained a moderate correlation with each other (r2 = 0.12, p<0.0005), and interacted clearly, as predictors of patient mortality. A low baseline GFR followed by a fast decline portended the worst survival outcome (adjusted HR 3.84, 95%CI 1.81–8.14, p<0.0005)(Ref. baseline GFR above median plus rate of decline below median). In general, the rate of decline of RKF had a greater effect on mortality than baseline GFR, which had no detectable effect on survival when the decline of RKF was slow (HR 1.17, 95% CI 0.81–2.22, p = 0.22). Conversely, a relatively high GFR at the start of PD still carried a significant risk of mortality, when RKF declined rapidly (HR 1.89, 95% CI 1.05–3.72, p = 0.028).ConclusionThe risk-benefit balance of an early versus late start of PD cannot be evaluated without taking into consideration the rate of decline of RKF. This circumstance may contribute to explain the controversial results observed at the time of evaluating the potential benefits of an early initiation of PD.

Background: There is controversy concerning the compared rates of decline of residual kidney function (RKF) in patients treated with continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). Objectives and Method: Following an observational, multicenter design, we studied 493 patients initiating peritoneal dialysis (PD) in four different Spanish units. We explored the effect of the PD modality on the rate of decline of RKF and the probability of anuria during follow-up. We applied logistic regression for intention-to-treat analyses, and linear mixed models to explore time-dependent variables, excluding those affected by indication bias. Main Results: Patients started on APD were younger and less comorbid than those initiated on CAPD. Baseline RKF was similar in both groups (p = 0.50). Eighty-seven patients changed their PD modality during follow-up. The following variables predicted a faster decline of RKF: higher (rate of decline) or lower (anuria) baseline RKF, younger age, proteinuria, nonprimary PD, use of PD solutions rich in glucose degradation products, higher blood pressure, and suffering peritonitis or cardiovascular events during follow-up. Overall, APD was not associated with a fast decline of RKF, but stratified analysis disclosed that patients with lower baseline RKF had an increased risk for this outcome when treated with this technique (HR: 2.26, 95% CI: 1.09-4.82, p = 0.023). Moreover, the probability of anuria during follow-up was overtly higher in APD patients (HR: 3.22, 95% CI: 1.25-6.69, p = 0.002). Conclusions: Starting PD patients directly on APD is associated with a faster decline of RKF and a higher risk of developing anuria than doing so on CAPD. This detrimental effect is more marked in patients initiating PD with lower levels of RKF.