NDT Advance Access published online on March 30, 2007
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfm109
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Delaying initiation of dialysis till symptomatic uraemia—is it too late?
1Division of Nephrology, Department of Medicine, The University of Hong Kong and Queen Mary Hospital and 2Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong SAR, China
Correspondence and offprint requests to: Sydney C. W. Tang, Department of Medicine, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China. Email: scwtang{at}hku.hk
 |
Abstract |
|---|
 Top Abstract IntroductionMaterials and methodsResultsDiscussionAcknowledgementsReferences |
|---|
Background. The optimal timing of initiating renal replacement therapy in patients with chronic renal failure remains uncertain. The primary objective of our study is to determine whether delaying dialysis initiation as a result of patients’ choice may have any impact on survival in subjects with end-stage renal disease.
Methods. We prospectively studied the clinical outcome during the first year of all consecutive patients (n = 233) deemed suitable for peritoneal dialysis (PD) after pre-dialysis counselling over a 2-year period from 2002 to 2004. All patients who were offered dialysis were included in the analysis from the day of initial counselling regardless of whether or not they were eventually established on PD.
Results. There were 151 ‘elective starters’ (50.3% male, mean ± SD age = 57.7 ± 13.9 years, 39.7% diabetic) who were electively initiated on dialysis when glomerular filtration rate reached 10 ml/min/1.73 m2 or below. The remaining 82 subjects (53.7% male, mean ± SD age = 58.4 ± 11.3 years, 46.3% diabetic, P = 0.33 vs elective starters) declined dialysis initially (initial refusers). On follow-up, 45 (55%) initial refusers developed a uraemic emergency and agreed to undergo dialysis, and 39 (48%) were eventually established on maintenance PD (late starters). Kaplan–Meier analysis of 1-year survival showed a significantly higher rate of all-cause (18.3% vs 6.6%, P = 0.004, log-rank test) and cardiovascular (9.8% vs 2.6%, P = 0.014) mortality among the initial refusers.
Conclusion. Patients who refuse timely start of dialysis have worse overall outcome at one year after the offer of dialysis, compared with elective starters.
Keywords: dialysis initiation; outcome; survival; uraemic symptoms
|
Introduction |
|---|
|
TopAbstractIntroductionMaterials and methodsResultsDiscussionAcknowledgementsReferences |
|---|
The optimal time to commence dialysis in patients with chronic renal failure remains unclear. A number of studies published in the last decade [1–4] supported the notion that starting dialysis at a relatively high level of glomerular filtration rate (GFR) may be beneficial in terms of morbidity, mortality, employment opportunity and quality of life. These studies, however, were confounded by various factors such as referral-time and lead-time bias, comorbidity, compliance, age and non-uniform dialysis regimens and techniques. Indeed, after eliminating lead-time bias, two recent reports revoked the potential benefits of early initiation of dialysis [5,6]. However, one of these studies comprising over 250 participants conducted in the Netherlands [6] has been criticized for not applying the appropriate standard of correction for such bias [7]. Therefore, the issue of how to correct for lead-time bias and when best to start dialysis has remained a matter of controversy and heated debate [8]. Nevertheless, the contemporary recommended threshold GFRs for initiating dialysis range from 10–12.5 ml/min [9,10].
Despite adequate pre-dialysis preparation and counselling, many patients either remain in denial of their renal disease or the need for dialysis, or simply cannot come to terms with the reality of having to initiate dialysis. And it is not unusual for the practicing nephrologist to encounter patients who refuse the commencement of dialysis until they develop significant symptoms of uraemia, fluid overload or malnutrition, when they become ‘forced’ to accept and commence dialysis. Delaying initiation literally to the ‘last minute’ may have profound implications on patients’ psychological well-being (extra time free of dialysis), overall healthcare economics and dialysis outcomes. While it may not be ethically feasible to randomize patients to delay dialysis till the onset of uraemic symptoms, the present study aims to prospectively compare the clinical course and outcome of patients who complied with elective commencement of dialysis and those who did not.
|
Materials and methods |
|---|
|
TopAbstractIntroductionMaterials and methodsResultsDiscussionAcknowledgementsReferences |
|---|
Patients
We prospectively followed the clinical outcome of all incident patients entering our peritoneal dialysis (PD) programme over a 2-year period from 2002 to2004. Continuous ambulatory peritoneal dialysis is the first line and most predominant form of dialytic therapy in Hong Kong [11]. All patients with chronic renal failure and their close relatives were invited to attend a multidisciplinary pre-dialysis counselling seminar jointly conducted by the renal physician, nurse specialist, dietician, rehabilitation physiotherapist, community rehabilitation nurse and medical social worker, when their reciprocal of serum creatinine vs time plot predicted that end-stage renal failure (GFR below 10 ml/min/1.73 m2) was impending within the next 6–12 months. Patients were then counselled individually by the nurse specialist in PD. Patients who accepted dialysis were scheduled for Tenckhoff catheter insertion followed immediately by initiation of intermittent PD (twice weekly, in-hospital, cycler-driven exchanges of 24–30 l of PD fluid lasting typically 3–5 weeks) until PD training. Patients who were commenced on PD in this manner were regarded as ‘elective starters’. Patients who were deemed suitable for PD but declined initiation despite adequate counselling were deemed ‘initial refusers’, and continued to be monitored at the low clearance clinic. The clinical outcome of elective starters and initial refusers were tracked from the moment dialysis was offered to them and all subsequent follow-up and comparisons between elective starters and initial refusers were based on this starting point. Outcome measures included all subjects who were offered dialysis, regardless of whether they were eventually established on dialysis or not, or received renal transplantation. Those initial refusers who subsequently developed uraemic symptoms or emergencies that prompted them to agree to be initiated on dialysis were considered ‘late starters’. Patients with inadequate documentation of GFR before the start of dialysis, history of malignancy and previous renal transplantation were excluded. The study protocol was reviewed and approved by the Clinical Research Ethics Committee and Institutional Review Board of the Hong Kong Hospital Authority.
GFR measurement before dialysis
Patients with serum creatinine over 400 µmol/l were regarded as having low clearance, and were followed at 4–6 weekly intervals. At each clinic visit, GFR was estimated by taking the average of urea and creatinine clearances calculated from 24-h urine samples and simultaneous serum urea and creatinine levels, and corrected for body surface area.
Dialysis protocol and follow-up
Upon the initiation of dialysis, the particular PD system employed was solely the choice of the patient after they had visited the PD centre and received detailed information from the nurse specialist on the various brands, modes and connectologies of PD. In Hong Kong, all dialysis solutions are provided free by its statutory healthcare regulatory organization, the Hong Kong Hospital Authority. Patients will only need to bear the cost of consumable items, such as connection tubings, and antiseptic solutions.
Patients performed 3–4 daily exchanges of 2 l PD fluid using either UltraBag (Baxter Healthcare, Guangzhou, People's Republic of China) or AndyDisk (Fresenius Medical Care, Bad Homburg, Germany) system. Adequacy of dialysis was assessed at the steady state when patients were established on PD for 
2 months. Peritoneal membrane transport properties were assessed at the same setting using standard peritoneal equilibration test [12]. Dialysis regimens were adjusted to achieve euvolaemia and a weekly peritoneal Kt/V of at least 1.7, as this level of adequacy is found to be a minimum target for incident Chinese subjects [13].
All pertinent clinical data during PD including peritonitis and other infective episodes, exit site-related problems, ultrafiltration status, dialysis adequacy, hospitalization record, blood transfusion, erythropoietin requirement and other drug prescriptions, and major adverse events were carefully documented.
Outcome measurements
The primary clinical outcomes evaluated were all-cause mortality and cardiovascular mortality. Cardiovascular mortality included death associated with a definite myocardial ischaemic event, heart failure, cerebrovascular accident and arrhythmia. Secondary outcomes included hospitalization and peritonitis rates, transfusion requirement, haemoglobin levels, nutritional status and transfer to another mode of renal replacement therapy. Initial refusers who underwent pre-emptive kidney transplantation and those who remained free of dialysis were not censored to avoid selection bias of patients with the worst prognosis in this group. If a patient died within 3 months of transfer to haemodialysis (HD), the death was not censored because such mortality was considered to reflect the health status during PD. During the period of follow-up, all deaths were accurately recorded with the exact cause of death provided by the attending physician. In the case of death out of hospital, family members were interviewed by telephone to ascertain the cause of death.
Statistical analyses
Data were expressed as means ± SD unless otherwise specified. Statistical analyses were performed using SPSS for Windows software version 12.0 (Statistical Package for the Social Sciences Inc., Chicago, IL, USA). Comparisons between groups were performed by 
2 test for categorical data, and Mann–Whitney U-test for continuous data. Cumulative one-year survival was calculated using the Kaplan–Meier method, and comparisons between groups were made with the log-rank test. Unadjusted and adjusted hazard ratios were calculated for elective starters and initial refusers by Cox's proportional-hazards regression analysis. We adjusted all ratios for age, sex, and GFR at the point of inclusion and primary diabetic kidney disease, since the latter is known to adversely affect overall outcome. P < 0.05 was considered significant. All probabilities were two-tailed.
|
Results |
|---|
|
TopAbstractIntroductionMaterials and methodsResultsDiscussionAcknowledgementsReferences |
|---|
A total of 233 subjects were recruited. There were 151 elective starters, and 82 initial refusers. The recruitment status is shown in Figure 1. Baseline demographic characteristics and clinical parameters are shown in Table 1. The following were the underlying renal diseases in the elective starters were: diabetes mellitus in 64 (42.4%), hypertensive nephrosclerosis in four (2.6%), polycystic kidney disease in two (1.3%), primary glomerulonephritis in 24 (15.9%), obstructive uropathy in four (2.6%), lupus nephritis in two (1.3%), chronic pyelonephritis in one (0.7%) and unknown in 50 (33.1%); while those for the initial refusers were as follows: diabetes mellitus in 39 (47.6%), hypertensive nephrosclerosis in five (6.1%), polycystic kidney disease in one (1.2%), primary glomerulonephritis in 15 (18.3%), obstructive uropathy in one (1.2%), lupus nephritis in one (1.2%), and unknown in 20 (24.4%). There was no significant difference in the prevalence of each primary kidney disease between the two groups.
|
|
The early clinical outcome of all subjects is summarized in Figure 1. Among the elective starters, nine patients were established on cycler-assisted continuous peritoneal dialysis (CCPD) out of personal preference, two failed Tenckhoff catheter insertion and were commenced on HD. The remaining 140 subjects underwent CAPD. Among the initial refusers, 12 (15%) underwent pre-emptive renal transplantation, and two (2.4%) were lost to follow-up. Sixty-eight subjects continued to be followed at the low clearance clinic. After a mean of 3.3 ± 0.7 months, 45 (55%) of them developed symptomatic uraemia or a uraemic emergency that prompted them or their family to retract their original refusal decision, and they were treated with emergency HD via a temporary dual lumen venous catheter. The reasons for initiating acute HD were as follows: shortness of breath in 16 (35.6%), significant nausea and vomiting in 10 (22.2%), significant oedematous state in 10 (22.2%), refractory hyperkalaemia with or without cardiac dysrhythmias in eight (17.8%), bleeding diathesis (epistaxis) in one (2.2%). Of these 45 subjects, 39 underwent Tenckhoff catheter insertion after a median of 2 weeks when their acute condition became stabilized with temporary intermittent HD, and were subsequently established on CAPD (late starters). Three patients died shortly after the commencement of temporary intermittent HD support (one from acute myocardial infarction, one from heart failure and one from sepsis). Another three patients revoked their decision to accept long-term dialysis once again after emergency HD, and subsequently died upon withdrawal of dialysis. The remaining 23 initial refusers continued to be followed at the low clearance clinic, and three patients died within the first year.
Patients were progressively enrolled into the study. The 1-year all-cause mortality was 6.6% among the elective starters, and 18.3% among the initial refusers (P = 0.004; Figure 2). The corresponding values for 1-year cardiovascular mortality were 2.6 and 9.8% (P = 0.014), respectively (Figure 3). The causes of death in each group were shown in Table 2. The results of the Cox proportional-hazard model are shown in Table 3. The unadjusted hazard ratio for overall survival among initial refusers compared with elective starters was 3.12 (95% CI 1.34–9.88, P = 0.011). After adjustment for age, sex, GFR and diabetic status, the hazard ratio was 3.01 (95% CI 1.32–9.40. P = 0.01).
|
|
|
|
Among elective starters and those initial refusers who were eventually established on maintenance dialysis (late starters), the steady-state peritoneal Kt/V for urea, peritoneal creatinine clearance and D/P for creatinine at 4 h were not different (Table 4). Renal Kt/V for urea and residual creatinine clearance were expectedly lower among late starters. Among secondary outcome measures, late starters had a higher number of hospital admissions (3.14 ± 1.17 vs 2.13 ± 1.13 episodes/person-year, P = 0.05), blood transfusion need (0.8 ± 0.35 vs 0.38 ± 0.07 episodes/person-year, P = 0.033), peritonitis rates (18 vs 42 patient-months/episode, P = 0.003) and lower serum albumin (30.9 ± 4.1 vs 34.0 ± 3.5 g/l, P = 0.01) and normalized protein catabolic rate (0.96 ± 0.37 vs 1.28 ± 0.30, P = 0.047) during the first year of dialysis. There were no significant differences in overall erythropoietin requirement, exit site problems and probability of receiving renal transplantation.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMaterials and methodsResultsDiscussionAcknowledgementsReferences |
|---|
A number of investigators have tried to explore the optimal timing of initiating dialysis by comparing clinical outcomes in patients with chronic renal failure starting dialysis at various pre-defined levels of GFR, and produced mixed and inconclusive results [2,6,14,15]. However, in real-life practice many patients approaching end-stage renal disease (ESRD) do not comply with these pre-defined GFR levels at which to initiate dialysis, but choose to delay the onset of dialysis for as long as they can in order to enjoy extra time free of dialysis. As a result, many patients are started on dialysis at GFR levels well below the recommended thresholds. To date, there has been no published trial that addresses the outcome of patients who are started on dialysis as late as the onset of symptomatic uraemia. Such trials are understandably difficult to conduct because of ethical considerations, and the possibility of life-threatening or irreversible complications when dialysis is started literally at the very ‘last moment’. The immediate advantages of delaying the initiation of dialysis include extra time without dialysis on the patient's part, and alleviation on the part of any healthcare system of the ever-escalating burden of renal replacement therapy, the aggregate cost of which has been projected to exceed US$ 1 trillion during the next decade [16]. However, it is not known whether such an approach may cast an adverse effect on clinical outcome.
In this prospective cohort study, we addressed this issue by comparing the outcome of patients who complied with starting dialysis at a pre-defined standard, and those who refused to undergo initiation of dialysis despite adequate counselling on the tangible risks of delaying renal replacement therapy. To avoid lead-time bias, we tracked the outcomes of all subjects from the point dialysis was recommended to them. The initial refusers probably represented a heterogeneous group of patients comprising at least three categories: (i) patients with prolonged denial of disease who would finally agree to commence dialysis upon the development of significant uraemic symptoms and the sensation of impending demise; (ii) patients who were determined from the outset not to undergo renal replacement therapy no matter what; (iii) patients who rejected the idea of dialysis firmly but actively sought alternative forms of renal replacement therapy such as pre-emptive transplantation. The final decision is possibly influenced by multiple factors, including individual preference and disease perception, socio-economic status, religious belief and educational and cultural background. And the issue is further complicated by an unpredictable swing from one decision to another. In this cohort, three initial refusers who had agreed to receive dialysis upon the development of uraemic symptoms finally decided to withdraw from treatment. From our data, it is apparent that although initial refusers as a group gained extra time off dialysis, this must be offset by significant survival disadvantages in the ensuing 12 months, taking into account all the counselled subjects regardless of whether they were eventually established on dialysis or not, or received pre-emptive renal transplantation. Our results showed that compared with elective starters, initial refusers had significantly worse overall as well as cardiovascular event-free survival at 1 year. Such survival disadvantage remained evident after adjusting for age, gender, GFR level upon recruitment and diabetic status, which is known to affect overall prognosis in the dialysis population. At the same time, one must not neglect the potential risk of over-fitting in our multivariate model, as the total number of cardiovascular deaths during this 1-year study was low.
Although approximately half of the initial refusers were eventually started on maintenance dialysis with comparable peritoneal adequacy indices, these late starters still fared worse than the elective starters. An important determinant was the lower residual renal function among the late starters. Indeed, a number of studies, including the recent reanalysis of the CANUSA study, have demonstrated that residual renal function, rather than peritoneal clearance, predicts survival [17–19]. A commonly held belief of the advantage conferred by residual renal function is that endogenous urine production helps maintain euvolaemia, thereby alleviating the burden of fluid overload on the cardiovascular system. More recently, we showed that residual renal function negatively correlates with all-cause and cardiovascular mortality in PD [20]. Another important determinant of volume status is peritoneal membrane transport characteristic, which is inversely related to patient and technique survival [21]. Here, there was no difference in dialysate to plasma creatinine ratio at 4 h between the two groups. Nevertheless, a recent study found that the predictive value of peritoneal membrane permeability needs to be interpreted in conjunction with residual renal function [22].
Greater residual renal function might be associated with better preserved renal endocrine function. This may be reflected by the greater transfusion requirement among the late starters, although there was no difference in erythropoietin usage, which may be confounded by the fact that its usage in Hong Kong is only partially reimbursed and many patients may not opt to receive erythropoietin due to financial constraint. Finally, greater small-solute clearances are associated with better dietary intake and better nutrition. We previously demonstrated significant and independent effect of residual renal function, but not PD solute clearance, on actual dietary protein, calorie and other nutrient intake in patients on CAPD [23]. In the present cohort, elective starters had higher serum albumin levels and marginally higher normalized protein catabolic rate. The latter may not be a satisfactory nutritional marker because of its mathematical coupling with Kt/V and creatinine clearance as they were all computed from the same 24-h urine and dialysate collection. In any case, better nutritional status among elective starters may be supported by their lower peritonitis and hospitalization rates.
In conclusion, patients who refused timely start of dialysis have worse overall outcome at 1 year after dialysis was offered to them, compared with elective starters. This is probably mediated through multiple mechanisms including accelerated atherosclerosis and heightened systemic inflammation, fluid overload, anaemia, anorexia, poorer nutritional status, increased vulnerability to infection and reduced compliance with therapy. Although the optimal timing of starting dialysis remains to be defined, initiating at the inception of uraemic symptoms is probably too late.
|
Acknowledgements |
|---|
|
TopAbstractIntroductionMaterials and methodsResultsDiscussionAcknowledgementsReferences |
|---|
Presented in abstract form at the 3rd World Congress of Nephrology, Singapore, 27–30 June 2005. The authors thank all nursing staff of the dialysis units at United Christian Hospital and Queen Mary Hospital for their assistance in providing pre-dialysis counselling and dialysis training to all patients. This work was supported in part by a grant from the Research Grant Council, Hong Kong (Grant number HKU 7452/04M).
Members of the Hong Kong Peritoneal Dialysis Study Group: Queen Mary Hospital—Sydney CW Tang, Angela YM Wang, Wai Kei Lo, Sing Leung Lui, Joseph CK Leung, Loretta YY Chan, Colin SO Tang, Man Fai Lam, Kai Chung Tse, Terence PS Yip, Frances H Chiu, Lily LY Lee, Joanna Poon, Helena Leung, Tak Mao Chan, Kar Neng Lai; United Christian Hospital—Anthony WC Tang, Ada YY Cheng, Woon Or Lam, San San Leung, Yiu Wing Ho.
Conflict of interest statement. None declared.
|
Notes |
|---|
*Members of the Study Group are listed under Acknowledgement.
|
References |
|---|
|
TopAbstractIntroductionMaterials and methodsResultsDiscussionAcknowledgementsReferences |
|---|
- McCusker FX, Teehan BP, Thorpe KE, Keshaviah PR, Churchill DN. (1996) How much peritoneal dialysis is required for the maintenance of a good nutritional state? Canada-USA (CANUSA) Peritoneal Dialysis Study Group. Kidney Int Suppl 56:S56–S61.[Medline]
- Tattersall J, Greenwood R, Farrington K. (1995) Urea kinetics and when to commence dialysis. Am J Nephrol 15:283–289.[Web of Science][Medline]
- Jungers P, Zingraff J, Albouze G, et al. (1993) Late referral to maintenance dialysis: detrimental consequences. Nephrol Dial Transplant 8:1089–1093.
[Abstract/Free Full Text] - Sesso R and Belasco AG. (1996) Late diagnosis of chronic renal failure and mortality on maintenance dialysis. Nephrol Dial Transplant 11:2417–2420.
[Abstract/Free Full Text] - Traynor JP, Simpson K, Geddes CC, Deighan CJ, Fox JG. (2002) Early initiation of dialysis fails to prolong survival in patients with end-stage renal failure. J Am Soc Nephrol 13:2125–2132.
[Abstract/Free Full Text] - Korevaar JC, Jansen MA, Dekker FW, et al. (2001) When to initiate dialysis: effect of proposed US guidelines on survival. Lancet 358:1046–1050.[CrossRef][Web of Science][Medline]
- Lameire N, Biesen WV, Vanholder R. (2002) Initiation of dialysis—is the problem solved by NECOSAD? Nephrol Dial Transplant 17:1550–1552.
[Free Full Text] - Korevaar JC, Dekker FW, Krediet RT. (2003) Initiation of dialysis: is the problem solved by NECOSAD? Nephrol Dial Transplant 18:1228–1229.
[Free Full Text] - NKF-K/DOQI. (2001) Clinical Practice Guidelines for Peritoneal Dialysis Adequacy: update 2000. Am J Kidney Dis 37:S65–S136.[Medline]
- Churchill DN, Blake PG, Jindal KK, Toffelmire EB, Goldstein MB. (1999) Clinical practice guidelines for initiation of dialysis. Canadian Society of Nephrology. J Am Soc Nephrol 10:Suppl 13, S289–S291.[CrossRef][Web of Science][Medline]
- Lai KN and Lo WK. (1999) Optimal peritoneal dialysis for patients from Hong Kong. Perit Dial Int 19:Suppl 3, S26–S31.
[Abstract/Free Full Text] - Twardowski ZJ. (1990) PET—a simpler approach for determining prescriptions for adequate dialysis therapy. Adv Perit Dial 6:186–191.[Medline]
- Lo WK, Ho YW, Li CS, et al. (2003) Effect of Kt/V on survival and clinical outcome in CAPD patients in a randomized prospective study. Kidney Int 64:649–656.[CrossRef][Web of Science][Medline]
- Bonomini V, Feletti C, Scolari MP, Stefoni S. (1985) Benefits of early initiation of dialysis. Kidney Int Suppl 17:S57–S59.[Medline]
- Fink JC, Burdick RA, Kurth SJ, et al. (1999) Significance of serum creatinine values in new end-stage renal disease patients. Am J Kidney Dis 34:694–701.[Web of Science][Medline]
- Lysaght MJ. (2002) Maintenance dialysis population dynamics: current trends and long-term implications. J Am Soc Nephrol 13:Suppl 1, S37–S40.
[Abstract/Free Full Text] - Bargman JM, Thorpe KE, Churchill DN. (2001) Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol 12:2158–2162.
[Abstract/Free Full Text] - Szeto CC, Wong TY, Leung CB, et al. (2000) Importance of dialysis adequacy in mortality and morbidity of chinese CAPD patients. Kidney Int 58:400–407.[CrossRef][Web of Science][Medline]
- Diaz-Buxo JA, Lowrie EG, Lew NL, et al. (1999) Associates of mortality among peritoneal dialysis patients with special reference to peritoneal transport rates and solute clearance. Am J Kidney Dis 33:523–534.[Web of Science][Medline]
- Wang AY, Wang M, Woo J, et al. (2004) Inflammation, residual kidney function, and cardiac hypertrophy are interrelated and combine adversely to enhance mortality and cardiovascular death risk of peritoneal dialysis patients. J Am Soc Nephrol 15:2186–2194.
[Abstract/Free Full Text] - Churchill DN, Thorpe KE, Nolph KD, et al. (1998) Increased peritoneal membrane transport is associated with decreased patient and technique survival for continuous peritoneal dialysis patients. The Canada-USA (CANUSA) Peritoneal Dialysis Study Group. J Am Soc Nephrol 9:1285–1292.[Abstract]
- Rodrigues AS, Almeida M, Fonseca I, et al. (2006) Peritoneal fast transport in incident peritoneal dialysis patients is not consistently associated with systemic inflammation. Nephrol Dial Transplant 21:763–769.
[Abstract/Free Full Text] - Wang AY, Sea MM, Ip R, et al. (2001) Independent effects of residual renal function and dialysis adequacy on actual dietary protein, calorie, and other nutrient intake in patients on continuous ambulatory peritoneal dialysis. J Am Soc Nephrol 12:2450–2457.
[Abstract/Free Full Text] - Keshaviah PR and Nolph KD. (1991) Protein catabolic rate calculations in CAPD patients. ASAIO Trans 37:M400–M402.[Medline]
Accepted in revised form: 8. 2.07
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  R. L. Mehta and J. Bouchard Dialysis Dosage in Acute Kidney Injury: Still a Conundrum? J. Am. Soc. Nephrol., June 1, 2008; 19(6): 1046 - 1048. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||