The aim of the present study was to evaluate the clinical efficacy of peritoneal dialysis (PD) in patients with severe lupus nephritis (LN) complicated with organ dysfunction. In total, 13 severe LN patients complicated with multiple-organ dysfunction, who underwent PD treatment between November 2003 and September 2010, were enrolled in the study. Six patients received methylprednisolone pulse therapy due to lupus activity and progressive renal failure. These patients were complicated with severe edema, cardiac insufficiency and severe hypoalbuminemia. PD was applied to the patients, followed by the administration of immunosuppressants. Patients were followed-up to review the parameters of renal function, the immunological indexes and the systemic lupus erythematosus disease activity index. The results indicated that the general state of health was markedly improved following PD treatment, with edema abatement and improvement of heart function and physical strength. Serum creatinine levels significantly decreased from 6.3±1.6 to 2.6±1.0 mg/dl. A total of 10 cases ceased PD treatment during the follow-up, while three cases continued PD to the end of the follow-up period. The levels of albumin and hemoglobin exhibited a marked increase from 29.7±5.7 to 35.2±5.5 g/l and 8.7±1.8 to 9.8±1.8 g/l, respectively. There was one case of peritonitis, one case of peritoneal leakage and two cases of pneumonia. Therefore, PD may be a successful treatment method for severe LN patients complicated with essential organ dysfunction. PD not only improved the symptoms of edema and heart failure, but also played an important role in preserving residual renal function and improving the nutritional state of the patients. Thus, PD can be considered as a treatment option for patients with severe LN associated with acute kidney injury, however, selecting a suitable immunosuppressant during PD treatment is essential.
Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disease which involves multiple organs. The disease is progressively aggravated without intervention. Therapy with immunosuppressants controls the progression of the disease in the early stages (
In total, 13 patients, including 10 females and 3 males with a mean age of 36.3±13.3 years (age range, 18–54 years) that had been admitted to the Department of Nephrology at Jinling Hospital (Nanjing, China) between November 2003 and September 2010, were included in the study. All the patients were diagnosed with severe LN with rapid progressive glomerulonephritis (RPGN). Among the patients, four individuals had heart diseases, including enlargement of the cardiothoracic ratio, slight or moderate pericardial effusion and pulmonary artery hypertension, and one patient had lupus encephalopathy. The present study was approved by the ethics committee of Nanjing University (Nanjing, China). All of the patients approved the present study and gave their informed consents.
A renal biopsy was performed in all the patients. According to the 2003 International Society of Nephrology/Renal Pathology Society classification criteria (
Open surgery was performed for PD catheter insertion. Patients were initially advised to have three to four daytime exchanges of one liter dextrose solution (1.5%). After one week, the patients were discharged and the PD prescription was changed to two liters dextrose solution [1.5 or 2.5% according to the urine (UV) and ultrafiltration volume] with three or four daytime exchanges.
All the patients underwent a peritoneal equilibration test at the outpatient department in the first month following discharge. Dialysate, urinary protein, urinary sediment, blood biochemistry, blood routine, autoantibody titer and complement levels were examined every two months. PD efficiency (Kt/V, Ccl) was also evaluated. The levels of albumin, hemoglobin, serum creatinine were detected using a Blood biochemistry detection kit (Tiangen, Beijing, China). Other observational indexes included RRF, nutrition, systemic lupus erythematosus disease activity index (SLE-DAI) and immunosuppressant and infectious complications.
Measurement data are expressed as the mean ± standard deviation. The Student's t-test was used to analyze the differences between the parameters prior to and following treatment. P<0.05 was considered to indicate a statistically significant difference. Analyses were performed using SPSS software (SPSS, Inc., Chicago, IL, USA).
Clinical and pathological observations at the baseline are shown in
Oral prednisone at a dose of 20–30 mg/day was administered to all the patients. Six patients received intravenous methylprednisolone pulse therapy (0.5 g/day for three days per patient) prior to PD.
The dialysis dose was six liters per day in 10 cases and 4 liters per day in the other three cases. Two cases were administered continuous ambulatory peritoneal dialysis (CAPD), while 11 cases received daytime ambulatory peritoneal dialysis (
Following PD, there were no patients with edema and the blood pressure was stable. No case developed heart failure and the indicators of renal function and serum Alb levels were all improved (
In total, 10 patients received oral mycophenolate (MMF) one month following PD. The dosage of MMF was initiated at 0.75–1.5 g twice daily and the concentration was measured after one or two months with three plasma samples, according to the strategy developed by Shaw
The mean follow-up time was 8.1±6.3 months (range, 4–26 months). At the last follow-up examination, the UV had significantly increased between 454.1±428.6 and 1333.6±475.8 ml (P<0.0001;
During the follow-up period, only one case developed peritonitis following diarrhea, and recovered via the administration of antibiotics. Two cases who received MMF treatment developed pneumonia, while one case developed peritoneal leakage.
In total, 13 severe LN patients with AKI that had undergone PD therapy were reported in the study. PD was demonstrated to be a simple, safe, gentle and efficient renal replacement therapy method, with the ability to correct AKI-induced metabolic, electrolytic and acid-base disorder and volume overload. Compared with hemodialysis (HD), PD has been associated with faster recovery of renal function in AKI and better maintenance of residual function in patients with CKD (
Data on PD treatment in severe LN cases are limited. Immunosuppressive therapy is the basic process to control lupus activity, however, this is limited in patients with complications such as RPGN or AKI. All the patients in the present study developed renal dysfunction to varying degrees, with Scr levels ranging between 4.24 and 9.48 mg/dl. Conditions worsened due to oliguria and congestive heart failure, particularly following methylprednisolone pulse therapy. In this situation, PD therapy was selected for support. The results demonstrated that PD had marked effects for these patients. The majority of patients had time for the recovery of renal function and, more importantly, these patients reached a stable homeostasis following the administration of PD for one month, thus, it was possible to reapply immunosuppressants. PD is suitable therapy for patients with a high catabolism, oliguria, anuria, severe innutrition, water-sodium retention, prerenal failure and cardiovascular problems. All of the patients were followed up until the present study was completed.
It has been reported that patients behave differently within a short time period due to rapidly progressive LN. In 10–20% of these patients, renal function may recover or partly recover within a four-month period (
Immunosuppressants may be applied timely and reasonably during the PD process in order to further treat the primary disease. Previous studies have largely focused on the impact of immunological insults on SLE patients following dialysis (
PD patients with LN have significantly lower predialysis levels of serum Alb and Hb compared with non-LN patients. In addition, LN patients are more likely to suffer from various infections due to hypoimmunity (
The incidence of infectious complications was high. In order to prevent these complications, prednisone treatment was decreased to 10 mg/day prior to surgery. Interventions to reduce catheter-associated infections included sterile placement techniques, appropriate local dressing and catheter care. Full-time doctors and nurses performed these procedures. Follow-up via telephone was regularly conducted by nurses. In the group of 13 patients, only one individual developed peritonitis and two patients developed pneumonia. In addition, the incision was difficult to heal and leakage of the dialysate occurred easily. Thus, two pockets were ligated during surgery and a small dosage of dialysate was applied following surgery; the initial dose was 1,000 ml per time and this was performed three to four times daily, gradually increasing the dose. All the patients healed without infection, with the exception of one case that had dialysate leakage. Following pausing PD and undergoing hemofiltration, the leakage was stopped and PD was continued.
The cost of PD is lower than hemofiltration. In the present study, the expenses of PD were $120 per week at a dose of 6,000 ml per day, while the expenses of hemofiltration were at least $714 per week. PD patients were able to manage by themselves conveniently without any interruption of daily life. The time of renal function recovery was difficult to estimate. A total of 10 patients in the group recovered in 1–4 months following PD. One case achieved gradual remission with PD over 15 months. Long-term hemofiltration is likely to result in a heavy economic burden.
PD not only improves the fluid and electrolyte imbalance, but also significantly reduces the effect of systemic cytokines. PD can clear cytokines, including interleukin (IL)-6, IL-10 and tumor necrosis factor-α (
In conclusion, PD is not only a replacement method, but also a therapy. PD is an adjuvant method that may be used for treating LN patients complicated with severe organ dysfunction. PD can preserve the RRF, improve the nutritional status of the patients and provide conditions and guarantees for further immunosuppressive therapy of SLE. In contrast to others studies, the results of the present study, with low infection and mortality rates coupled with a high rate of recovery of renal function, indicate that PD can be considered as a treatment option for patients with severe LN and AKI who require ongoing immunosuppressive therapy.
Changes in the UV in patients undergoing PD. *P<0.05, **P<0.01 and ***P<0.001, vs. 0 month. PD, peritoneal dialysis; UV, urine volume.
Changes in the Scr levels in patients undergoing PD. *P<0.05 and **P<0.01, vs. 0 month. PD, peritoneal dialysis; Scr, serum creatinine.
Changes in the serum Alb levels in patients undergoing PD. *P<0.05, vs 0 month. PD, peritoneal dialysis; Alb, albumin.
Baseline clinical and renal pathological characteristics.
Case | Gender | Age (years) | BUN (mg/dl) | Scr (mg/dl) | Pathology | Crescents (%) |
---|---|---|---|---|---|---|
1 | F | 41 | 50 | 6.6 | Class IV, TMA | 0 |
2 | F | 51 | 94 | 4.2 | Class IV + V | 10, fibrocellular |
3 | M | 24 | 137 | 9.5 | Class IV + V | 83, fibrocellular |
4 | F | 24 | 79 | 7.5 | Class IV, 53% glomerular sclerosis | 40, fibrocellular |
5 | F | 54 | 103 | 6.1 | Class IV, TMA | 0 |
6 | F | 21 | 106 | 5.5 | Class IV + V | 27, fibrocellular |
7 | M | 44 | 93 | 6.7 | Class IV, 59% glomerular sclerosis | 28, cellular |
8 | M | 18 | 77 | 4.4 | Class V + IV | 77, cellular |
9 | F | 43 | 120 | 8.2 | Class IV | 84, cellular |
10 | F | 41 | 112 | 5.4 | Class IV | 0 |
11 | F | 41 | 69 | 4.3 | Class IV | 16, cellular |
12 | F | 35 | 44 | 9.3 | Class IV + V, TMA | 6.5, fibrocellular; Class IV 16, fibro |
13 | F | 46 | 46 | 8.5 | Class III | 26.7 fibrocellular |
F, female; M, male; Scr, serum creatinine; BUN, blood urea nitrogen; TMA, thrombotic microangiopathy.
Clinical and dialysis indexes of the 13 patients prior to discharge.
Alb (g/l) | Scr (mg/dl) | UV (ml/day) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
Case | Dialysis prescription (ml/day) | Time (days) | Edema | UFV (ml/day) | Pre PD | Discharge | Pre PD | Discharge | Pre PD | Discharge |
1 | CAPD, 6000 | 14 | No | 1000 | 38.3 | 39.3 | 6.58 | 5.68 | 0 | 100 |
2 | DAPD, 6000 | 27 | No | 200 | 27.2 | 21.6 | 4.24 | 8.04 | 0 | 400 |
3 | DAPD, 4000 | 11 | No | 100 | 26.6 | 26.6 | 9.48 | 3.80 | 1400 | 400 |
4 | DAPD, 6000 | 8 | No | 100 | 21.0 | 21.2 | 7.49 | 7.30 | 300 | 800 |
5 | DAPD, 6000 | 7 | No | 0 | 27.9 | 30.3 | 6.14 | 6.83 | 200 | 200 |
6 | DAPD, 6000 | 12 | No | 700 | 31.1 | 31.6 | 5.52 | 4.22 | 700 | 1000 |
7 | DAPD, 6000 | 9 | No | 0 | 29.1 | 29.1 | 6.69 | 6.29 | 800 | 800 |
8 | DAPD, 6000 | 11 | No | 600 | 28.3 | 27.6 | 5.37 | 5.39 | 150 | 200 |
9 | CAPD, 6000 | 23 | No | 1500 | 23.8 | 27.4 | 8.23 | 4.26 | 370 | 500 |
10 | DAPD, 4000 | 9 | No | 100 | 33.0 | 34.3 | 5.42 | 3.89 | 810 | 900 |
11 | DAPD, 4000 | 16 | No | 100 | 40.4 | 38.6 | 4.26 | 3.73 | 265 | 1100 |
12 | DAPD, 6000 | 8 | No | 0 | 29.5 | 31.1 | 9.33 | 7.72 | 300 | 1500 |
13 | DAPD, 6000 | 7 | No | 100 | 30.4 | 39.3 | 8.46 | 6.58 | 600 | 100 |
All of the patients suffered from edema, however, edema disappeared when the patients left the hospital. In this Table, the out-hospital results are shown. UFV, ultrafiltration volume; Alb, albumin; UV, urine volume; Scr, serum creatinine; CAPD, continuous ambulatory peritoneal dialysis; DAPD, daytime ambulatory peritoneal dialysis; PD, peritoneal dialysis.
Clinical and dialysis indexes of the 13 patients during the follow-up.
rGFR (ml/min) | Alb (g/l) | Scr (mg/dl) | Hb (g/dl) | UV (ml/day) | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Case | Dialysis prescription (ml/day) | Follow-up (months) | Outcome | Pre PD | Post PD | Pre PD | Post PD | Pre PD | Post PD | Pre PD | Post PD | Pre PD | Post PD |
1 | CAPD, 6000 | 26 | Discontinued | 0.0 | 11.6 | 38.3 | 43.8 | 6.58 | 2.70 | 4.9 | 12.3 | 0 | 2000 |
2 | DAPD, 6000 | 4 | Discontinued | 0.0 | 21.6 | 27.2 | 25.1 | 4.24 | 1.29 | 7.9 | 7.8 | 0 | 1500 |
3 | DAPD, 4000 | 6 | Continued | 7.3 | 18.1 | 26.6 | 38.7 | 9.48 | 3.18 | 9.0 | 10.7 | 1400 | 1300 |
4 | DAPD, 6000 | 4 | Discontinued | 7.1 | 19.9 | 21.0 | 34.6 | 7.49 | 3.05 | 9.3 | 6.7 | 300 | 600 |
5 | DAPD, 6000 | 4 | Discontinued | 9.2 | 19.1 | 27.9 | 35.7 | 6.14 | 1.61 | 6.9 | 9.2 | 200 | 1500 |
6 | DAPD, 6000 | 16 | Continued | 4.0 | 10.1 | 31.1 | 38.2 | 5.52 | 3.60 | 8.9 | 10.3 | 700 | 1400 |
7 | DAPD, 6000 | 5 | Discontinued | 5.5 | 7.9 | 29.1 | 29.1 | 6.69 | 4.33 | 8.4 | 8.7 | 800 | 1000 |
8 | DAPD, 6000 | 9 | Continued | 1.5 | 9.4 | 28.3 | 35.5 | 5.37 | 2.70 | 10.4 | 8.8 | 150 | 670 |
9 | CAPD, 6000 | 9 | Discontinued | 1.8 | 16.3 | 23.8 | 29.4 | 8.23 | 2.56 | 8.3 | 10.3 | 370 | 1500 |
10 | DAPD, 4000 | 5 | Discontinued | 9.2 | 23.0 | 33.0 | 38.6 | 5.42 | 1.42 | 11.5 | 12.7 | 810 | 2100 |
11 | DAPD, 4000 | 5 | Discontinued | 5.8 | 13.2 | 40.4 | 38.4 | 4.26 | 1.62 | 10.3 | 10.4 | 265 | 1100 |
12 | DAPD, 6000 | 7 | Discontinued | 3.6 | 27.9 | 29.5 | 38.7 | 9.33 | 1.55 | 5.4 | 9.5 | 300 | 1800 |
13 | DAPD, 6000 | 5 | Discontinued | 5.4 | 28.0 | 30.4 | 34.3 | 8.46 | 1.76 | 4.8 | 11.6 | 600 | 1600 |
Post PD refers to the last follow-up examination. CAPD, continuous ambulatory peritoneal dialysis; DAPD, daytime ambulatory peritoneal dialysis; rGFR, residual glomerular filtration rate; PD, peritoneal dialysis; Alb, albumin; Scr, serum creatinine; Hb, hemoglobin; UV, urine volume.