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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">The development of abdominal hernias is a factor that can lead to peritoneal dialysis &#40;PD&#41; failure&#46; Infusing dialysis fluid causes intraabdominal pressure to increase&#44; which promotes abdominal hernias in PD patients&#46; The aim of this study is to understand the risk factors that contribute to abdominal hernia in PD patients&#44; so as to inform the clinician of preventative measures&#46; We will also review how hernias can be treated and how they evolve&#46;</p><p class="elsevierStylePara">The study included all incident and prevalent PD patients at the Arnau de Vilanova Hospital&#44; Lleida &#40;Spain&#41;&#44; over the past 6 years &#40;2003-2009&#41;&#46;</p><p class="elsevierStylePara">The following variables were analysed&#58; age&#44; sex&#44; primary kidney disease&#44; diabetes mellitus &#40;DM&#41;&#44; body mass index &#40;BMI&#41;&#44; PD modality&#44; PD time&#44; interval between dialysis start-up and catheter insertion&#44; maximum daytime infusion volume &#40;MDV&#41; and body surface &#40;BS&#41;-adjusted MDV &#40;MDV&#47;BS&#41;&#44; maximum night-time infusion volume &#40;MNV&#41; and BS-adjusted MNV &#40;MNV&#47;BS&#41;&#44; abdominal surgery and hernias prior to PD&#46;</p><p class="elsevierStylePara">We included a total of 146 patients with an average age of 58&#46;15&#177;1&#46;4 years&#59; 101 men &#40;69&#46;2&#37;&#41; and 45 women &#40;30&#46;8&#37;&#41;&#59; 33&#46;56&#37; were diabetic&#46; Accumulated PD monitoring time was 3738&#46;2 months and PD time was 26&#46;26&#177;22&#46;75 months&#46; PD modality&#58; 73 patients &#40;50&#37;&#41; were treated with continuous ambulatory PD &#40;CAPD&#41; and 73 &#40;50&#37;&#41; with automated PD &#40;APD&#41;&#46; Our patients&#8217; primary kidney diseases were&#58; diabetic nephropathy &#40;26&#46;71&#37;&#41;&#44; nephroangiosclerosis &#40;24&#37;&#41;&#44; systemic diseases &#40;19&#46;86&#37;&#41;&#44; interstitial nephropathy &#40;14&#37;&#41;&#44; unknown &#40;12&#46;31&#37;&#41;&#44; polycystic kidney disease &#40;2&#37;&#41; and other diseases &#40;2&#37;&#41;&#46; Twelve patients &#40;8&#46;3&#37;&#41; developed abdominal hernias &#40;seven were inguinal&#44; four umbilical&#44; and one crural&#41;&#46; No incisional or pericatheter hernias were observed in the follow-up period&#46; Hernia rate was 0&#46;04&#47;patient&#47;year&#46; Hernias developed after an average of 5&#46;3 months of PD&#46; All hernias were intervened by placing a mesh&#59; none were recurrent&#46; Table 1 shows data comparing patients with and without hernias&#46;</p><p class="elsevierStylePara">The hernia rate in our PD population is comparable to those published in other studies&#46;<span class="elsevierStyleSup">1&#44;2</span> The only factor that predisposed patients to hernia development was history of abdominal hernias before inclusion in the study&#46; However&#44; patients with hernias were elderly&#44; almost ten years older than those patients that did not develop hernias during PD&#46; As it has been observed in other studies&#44;<span class="elsevierStyleSup">1&#44;3</span> the infusion volume did not influence abdominal hernia development during PD&#46; Intraperitoneal hydrostatic pressure proportionally increased with augmenting the infused volume&#46; Furthermore&#44; it could not predict whether the patient will develop abdominal hernias&#44;<span class="elsevierStyleSup">3</span> although pressure should not exceed 20cm H<span class="elsevierStyleInf">2</span>O&#46; Despite these results&#44; infusion volume increase should be limited&#44; especially in older patients&#44; those with a history of abdominal hernia or ultrafiltration problems&#46; In our unit&#44; the volume prescription varied&#44; according to the patient&#8217;s needs&#44; from 1-1&#46;5l&#47;m<span class="elsevierStyleSup">2</span> of the body surface-area&#46;</p><p class="elsevierStylePara">A higher incidence of hernias has been described for patients undergoing PD with polycystic disease&#44;<span class="elsevierStyleSup">4&#44;5</span> due to an intraabdominal pressure increase caused by polycystic kidneys or primary collagen disorders&#46; In our study&#44; only 2 patients had polycystic kidney disease&#44; which did not allow us to analyse the impact that the polycystic disease has on the risk of developing hernias during PD&#46;</p><p class="elsevierStylePara">Some studies<span class="elsevierStyleSup">1&#44;2 </span>state that there is lower prevalence of hernias in APD-treated patients than in CAPD-treated patients&#46; We have not found any statistically significant difference between the two techniques&#46; However&#44; APD patients used the same daytime volume as the CAPD patients &#40;1756&#43;ml compared with 1763&#43;ml&#44; respectively&#59; <span class="elsevierStyleItalic">P</span>&#61;0&#46;92&#47;0&#46;45&#41;&#46; These results do not correlate with those of other studies where greater daytime volumes were used for APD patients&#44; which could explain why the results were different&#46; Furthermore&#44; it supports the hypothesis that increasing intraabdominal pressure in a sitting and decubitus position could cause an increase in hernia development during CAPD&#46;</p><p class="elsevierStylePara">We treated all hernias with surgery&#44; placing a mesh&#44; and evolution was successful&#44; with no recurrences&#46; A mesh significantly reduces recurrence<span class="elsevierStyleSup">6</span><span class="elsevierStyleSup"> </span>and should be used when repairing hernias in patients at risk of recurrence or new hernias&#44; such those undergoing PD&#46;</p><p class="elsevierStylePara">To summarise&#44; PD patients with a history of hernia have a greater risk of developing abdominal hernias upon starting treatment&#46; We recommend systematically examining for abdominal hernias in patients before starting PD treatment&#44; and if patients present with clinical signs compatible with abdominal hernia&#44; this complication should be suspected&#46; If surgical repair is necessary&#44; a mesh should be placed&#46; Although abdominal hernias are a relatively frequent complication during PD&#44; if treated correctly the patient&#8217;s condition improves&#44; proving that that this complication should not be a motive for not using this technique&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10659&#95;108&#95;15823&#95;en&#95;t1&#95;carta&#46;jpg" class="elsevierStyleCrossRefs"><img src="10659_108_15823_en_t1_carta.jpg" alt="Comparative data between populations with and without hernia"></img></a></p><p class="elsevierStylePara">Table 1&#46; Comparative data between populations with and without hernia</p>"
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