bluuebunny/crossref_metadata_2025 huggingface dataset:
Prophylaxis against Gram-Positive Organisms Causing Exit-Site Infection and Peritonitis in Continuous Ambulatory Peritoneal Dialysis Patients by Applying Mupirocin Ointment at the Catheter Exit Site
Authors: Wong Sunny S.H. , Chu Kwok Hong , Cheuk Au , Tsang Wai Kay , Fung Samuel K.S. , Chan Hilda W.H. , Tong Matthew K.L.
Published: February 2020

Objective

We evaluated the effectiveness of local application of mupirocin ointment at the catheter exit site in preventing exit-site infection and peritonitis attributable to gram-positive organisms in continuous ambulatory peritoneal dialysis patients.

Methods

This prospective randomized controlled trial included 154 patients. They were randomly allocated to a mupirocin-treated group (group M) and a control group (group C). Group M included 73 patients (47.4%) who were instructed to apply mupirocin ointment to the catheter exit site once daily after the routine daily exit-site dressing. Group C included 81 patients (52.6%) who continued their usual daily exit-site care without applying mupirocin. The two groups were followed to see whether there would be any difference in the frequency of exit-site infection and peritonitis or in the infecting organisms.

Results

Interim data were collected at 5 months after the start of the study. Those data showed a significantly lower incidence of exit-site infection and peritonitis attributable to gram-positive organisms in group M as compared with group C. The incidence of gram-positive exit-site infection in group C was 1 episode per 36.8 patient–months; in group M, the incidence was 1 episode per ∞ patient–months (0 incidence in 5 months, p < 0.05). The incidence of gram-positive peritonitis in group C was 1 episode per 40.5 patient–months; in group M, the incidence was 1 episode per 365 patient–months ( p < 0.05). Mupirocin treatment had no significant effect on the incidence of exit-site infection and peritonitis attributable to other organisms. Before mupirocin treatment, we saw a trend toward higher infection rates in diabetic patients and nasal carriers of Staphylococcus aureus as compared with non diabetic patients and nasal non carriers, although the differences were not statistically significant. Mupirocin brought the infection rate attributable to gram-positive organisms to an equally low level in diabetic and non-diabetic patients, and in nasal carriers and nasal non carriers of S. aureus. No adverse effect of local application of mupirocin was reported.

Conclusion

Local application of mupirocin ointment at the catheter exit site is a safe and effective method of preventing exit-site infection and peritonitis involving gram-positive organisms.
Health Issues in Dialysis-Dependent Female Patients
Authors: Shanmugavadivoo Kulamthaivel , Shaariah Wan
Published: February 2020

Background

Reproductive health issues in women with end-stage renal disease (ESRD) are often neglected. Data on these issues are also limited.

Purpose

We set out to describe the reproductive health issues in women being treated with either hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD).

Patients and Methods

All adult female patients on chronic dialysis in Hospital Seremban from January 1991 to December 2001 were included in our study. Patients (or their spouses or children) were interviewed regarding the menstrual status of the patient, gynecologic screening tests administered to the patient, and the patient's use of hormone replacement therapy (HRT).

Results

We recruited 137 women into the study. Of those women, 52.6% were on HD; the rest were on CAPD. Mean age at diagnosis of ESRD was 46.5 ± 14.1 years (range: 14 – 82 years), and mean duration on dialysis was 33.3 months (range: 2 months – 18 years). Responses about menstrual status were obtained for 118 patients. Of those 118 patients, 55 (46.6%) were postmenopausal at dialysis initiation. Average age at menopause had been 48.5 ± 4.9 years. Another 19 patients (16.1%) had still been menstruating at dialysis initiation, but subsequently entered menopause. Their average age at menopause had been 45.1 ± 10.3 years. The remaining 44 patients (37.3%) were still menstruating at an average age of 35.7 years (range: 15 – 49 years). Only 3 of 73 responders were on HRT; 63% had undergone a Pap smear; and 54% had had a breast examination.

Conclusions

Patients with ESRD tend to experience premature menopause. Not all dialysis patients are amenorrheic. Despite frequent contact between dialysis patients and hospital staff, gynecologic screening and use of HRT in those patients are still very low.
Acute Peritoneal Dialysis in Eastern Nepal
Authors: Sharma Sanjib K. , Manandhar Dhiraj , Singh Jagpal , Chauhan Harshand S. , Koirala Biswanath , Gautam Mani , Ghotekar LeklaRaj H. , Tamang Bangbu , Gurung Shova
Published: February 2020

Objective

B.P. Koirala Institute of Health Sciences is the only dialysis center outside the capital city of Nepal. Although the burden of renal failure in Nepal is high, limited resources and dialysis facilities are the major constraint on management of acute renal failure (ARF) and acute dialysis in chronic renal failure (CRF). In the present study, carried out from January 2000 to June 2002, we looked into the prospect of introducing peritoneal dialysis (PD) to the district hospitals for treatment of ARF and acute dialysis in CRF.

Patients and Methods

We designed a form to evaulate the causes of renal failure and the indications for, complications of, and outcomes of dialysis. During this study, junior doctors in our hospitals completed the forms. Resident doctors were trained to do intermittent peritoneal dialysis (IPD) and were responsible for the carrying out the procedure under supervision, together with a staff nurse.

Results

A total of 120 patients underwent IPD during the study period, including 66 men and 54 women. The most common indications for acute dialysis in CRF were metabolic acidosis (56%), uremic encephalopathy (45%), and fluid overload (44%). The most common causes of ARF were acute gastroenteritis (20%), sepsis (20%), and septic abortion (16%). Fifteen patients died of sepsis and multi-organ failure.

Conclusions

Lack of dialysis facilities in the geographic periphery means that most patients present late in the course of their disease, as evidenced by severe metabolic acidosis and uremic encephalopathy. Peritoneal dialysis is a simple procedure, easily tolerated by the patient and requiring less expertise than hemodialysis does. Moreover, nursing staff, technicians, and doctors can be easily trained in the technique. Despite certain limitations, PD still has much potential and can be successfully accomplished in district hospitals and less accessible areas.
Impact of Fill Volume on Peritoneal Clearances and Cytokine Appearance in Peritoneal Dialysis
Authors: Paniagua Ramón , de Jesús Ventura María , Rodríguez Ernesto , Sil Juana , Galindo Teresa , Hurtado María Elena , Alcántara Guadalupe , Chimalpopoca Amado , González Isabel , Sanjurjo Abraham , Barrón Lourdes , Amato Dante , Mujais Salim
Published: February 2020

Background

Current adequacy guidelines for peritoneal dialysis encourage the use of large fill volumes for the attainment of small solute clearance targets. These guidelines have influenced clinical practice in a significant way, and adoption of higher fill volumes has become common in North America. Several studies, however, have challenged the relevance of increasing small solute clearance; this practice may result in untoward consequences in patients.

Objective

The present study was designed to explore the relationship between dialysate volume and the clearance of different sized molecules, fluid dynamics, and appearance of peritoneal cytokines.

Methods

Thirteen adult prevalent patients on continuous ambulatory peritoneal dialysis were studied. Three different dialysate volumes (2.0, 2.5, and 3.0 L) were infused on consecutive days in a random order. Several measurements of peritoneal fluid dynamics (intraperitoneal pressure, net ultrafiltration, fluid absorption), solute clearances (urea, creatinine, β2-microglobulin, albumin, IgG, and transferrin), and appearance of interleukin-6 and tumor necrosis factor alpha (TNFα) were assessed.

Results

Increase in dialysate fill volume (from 2 to 2.5 to 3 L) was examined in relationship to body surface area (BSA). The dialysate volume/BSA (DV/BSA) ratio increased from 1262 to 1566 to 1871 mL/m2 on 2.0, 2.5, and 3.0 L dialysate volumes, respectively. In parallel, diastolic blood pressure increased from 82.7 ± 8.8 to 87.0 ± 9.5 to 92 ± 8.3 mmHg ( p < 0.05). Net ultrafiltration rate also increased, from 0.46 ± 0.48 to 0.72 ± 0.42 to 0.97 ± 0.49 mL/minute ( p < 0.01), despite a concomitant increase in fluid absorption, from 1.05 ± 0.34 to 1.21 ± 0.40 to 1.56 ± 0.22 mL/min ( p < 0.01). Urea peritoneal clearance increased from 8.27 ± 0.68 to 9.92 ± 1.6 to 12.98 ± 4.03 mL/min ( p < 0.01); creatinine peritoneal clearance increased from 6.69 ± 1.01 to 7.64 ± 1.12 to 8.69 ± 1.76 mL/min ( p < 0.01). Clearance of the other measured molecules did not change. Appearance of interleukin-6 increased 17% and 43% ( p < 0.01), and TNFα appearance increased 14% and 50% ( p < 0.01) when dialysate volumes of 2.5 and 3.0 L were used, compared with 2.0 L.

Conclusions

These results show that, with higher values of DV/BSA ratio, small solute peritoneal clearance is increased, but clearances of large molecules remain unchanged. With the use of higher volumes, fluid absorption rate and the appearance of proinflammatory cytokines in the dialysate are increased.
Bone Mineral Density: Serum Markers of Bone Turnover and Their Relationships in Peritoneal Dialysis
Authors: Negri Armando L. , Barone Roberto , Quiroga Mabel Alvarez , Bravo Marina , Marino Alicia , Fradinger Erich , Bogado Cesar E. , Zanchetta Jose R.
Published: February 2020

Background

The usefulness of bone mass measurements and bone turnover markers to estimate the risk of fracture and the type of underlying renal osteodystrophy are not well established in patients on peritoneal dialysis (PD).

Objective

To assess bone mass using total and regional bone densitometry in a group of patients on PD and to determine if serum markers of bone turnover identify patients with low bone mass.

Methods

Bone densitometry was studied by dual-energy x-ray absorptiometry (DEXA), and bone turnover using several serum markers, in 65 patients on PD. Bone mass was classified as normal, osteopenic, or osteoporotic according to World Health Organization criteria based on bone mineral density (BMD) T scores.

Results

T scores in the osteopenia range were present at the lumbar spine (LS) in 44.6% (45% of men and 44.4% of women) of patients and at the femoral neck (FN) in 56.9% (55% of men and 58% of women). T scores in the osteoporosis range were present at the LS in 13.8% of patients (10% of men and 15.5% of women) and at the FN in 21.5% (30% of men and 17.7% of women). Patients with BMD T scores in the osteoporosis range at both regions had increased serum intact parathyroid hormone (iPTH) levels compared to patients in the osteopenic/normal range. Bone mineral content in the whole skeleton (TBMC) correlated negatively with iPTH ( r = –0.34) and with total time on dialysis ( r = –0.26); in multivariate analysis, only iPTH correlated negatively with TBMC ( B = –0.26, p = 0.03). No correlations were found between the other bone markers and BMD T scores at the FN or LS. There were no significant differences in absolute BMD or BMD T scores at the LS or FN between patients with and patients without fractures.

Conclusions

BMD T scores in the osteopenia/osteoporosis range were observed at the LS in 58.4% of these patients on PD and at the FN in 78.4%. TBMC correlated negatively with iPTH. There were no correlations between markers of bone turnover and bone mass measurements at the two skeletal regions, although patients with BMD T scores in the osteoporosis range had increased serum iPTH levels. Bone mass measurements were not different between patients with and patients without fractures.
The Initiating Dialysis Early and Late (Ideal) Study: Study Rationale and Design
Authors:   The IDEAL Study Steering Committee, Cooper Bruce A. , Branley Pauline , Bulfone Liliana , Collins John F. , Craig Jonathan C. , Dempster Jenny , Fraenkel Margaret B. , Harris Anthony , Harris David C. , Johnson David W. , Kesselhut Joan , Luxton Grant , Pilmore Andrew , Pollock Carol A. , Tiller David J.
Published: February 2020

Objectives

The primary objective of the IDEAL study is to determine whether the timing of dialysis initiation has an effect on survival in subjects with end-stage renal disease (ESRD). The secondary objectives are to determine the impact of “early start” versus “late start” dialysis on nutritional and cardiac morbidity, quality of life, and economic cost.

Design

Prospective multicenter randomized controlled trial. Patients are randomized to commence dialysis at a glomerular filtration rate (by Cockcroft–Gault) of either 10 – 14 mL/minute/1.73 m2 (“early start”) or 5 – 7 mL/min/1.73 m2 (“late start”), with stratification for dialysis modality (hemodialysis vs peritoneal dialysis), study center, and the presence or not of diabetes mellitus.

Setting

Dialysis units throughout Australia and New Zealand.

Patients

Patients with ESRD commencing chronic dialysis therapy.

Outcome Measures

Three years from randomization, all-cause mortality, morbidity, and economic impact; structural and functional cardiac status, nutritional state, and quality of life will be assessed.

Results

To date, 388 patients of a minimum 800 patients have been entered and randomized into the study. Current recruitment rates suggest sufficient patients will be enrolled by December 2004 and follow-up completed by December 2007.

Conclusions

The IDEAL study will provide evidence for the optimal time to commence dialysis.
Management of Renal Osteodystrophy in Peritoneal Dialysis Patients
Authors: Moe Sharon M.
Published: February 2020

The term “renal osteodystrophy” encompasses all forms of metabolic bone disease found in dialysis patients. The primary approach to the treatment of renal osteodystrophy in peritoneal dialysis (PD) patients is similar to that in hemodialysis patients. However, the increased prevalence of adynamic bone histology, together with the difficulty in judging calcium balance, the inability to practicably give intravenous vitamin D, and the clearance of vitamin D and parathyroid hormone via dialysate require a different therapeutic approach in PD compared to hemodialysis patients. Clearly, more comparative studies of new agents are needed to find the optimal approach to achieving the K/DOQI guidelines in PD patients. The unique aspects of the approach to renal osteodystrophy in PD patients are the focus of this review.
Relationship of Demographic, Dietary, and Clinical Factors to the Hydration Status of Patients on Peritoneal Dialysis
Authors: Asghar Ramzana B. , Green Sandra , Engel Barbara , Davies Simon J.
Published: February 2020

Objectives

To establish which clinical factors are associated with an increased proportion of extracellular fluid (ECF) in peritoneal dialysis (PD) patients.

Design

A single-center, cross-sectional analysis of 68 stable PD patients.

Method

Bioelectrical impedance measurements (RJL, single frequency; RJL Systems, Clinton, Michigan, USA) of resistance and reactance were used to determine the proportion of ECF comprising total body water (TBW) in 68 stable PD patients attending for routine clearance and membrane studies. All patients underwent detailed dietetic, adequacy, and membrane function tests. Blood pressure and antihypertensive requirements were also documented.

Results

Significant gender differences in body composition were observed, such that women had lower absolute TBW and fat-free mass per kilogram body weight, but proportionately more ECF for a given TBW, mean ECF:TBW 0.5 ± 0.03 versus 0.44 ± 0.05, p < 0.005. In view of this, patients were split into two groups, defined as “over-” or “normally” hydrated, either by using the single discriminator (median ECF:TBW = 0.47) for the whole population, which resulted in groups distorted by gender, or by using different discriminators according to gender (women: 0.49, men 0.45). In both analyses, overhydrated patients were older, had significantly lower plasma albumin, less total fluid removal per kilogram body weight, and higher peritoneal solute transport. When split by a single discriminator, the overhydrated patients had lower sodium removal and significantly less intracellular fluid volume due to an excess of women in this group who also had less residual function and had been on dialysis longer. Using gender-specific discrimination, overhydrated patients were heavier due to expansion of the ECF volume: 20 ± 4.1 L versus 16 ± 3.3 L, p < 0.001. Stepwise multivariate analysis found age ( p = 0.001), albumin ( p = 0.009), and fluid losses per kilogram body weight ( p = 0.025) to be independent predictors of gender-adjusted hydration status. Sodium intake did not vary according to hydration status.

Conclusion

Gender influences the assessment of hydration status of PD patients when employing bioimpedance, such that women tend to have more ECF. Taking this into account, age, albumin, and achieved fluid removal appear to be independently associated with hydration status, whereas peritoneal solute transport is not. Advice on dietary sodium should take account of hydration status and achievable losses.
Protein Adsorption on EX VIVO Catheters and Polymers Exposed to Peritoneal Dialysis Effluent
Authors: Yanagisawa Naoko , Li Dai-Qing , Ljungh Åsa
Published: February 2020

Background

Deposition of proteins on surfaces of medical devices has been recognized to putatively relate to the process of regulation of biomaterial-associated complications by attachment of fibrin clots, eukaryotic cells, and microbes. The molecules adsorb to a varying extent, depending not only on the physicochemical properties of the biomaterial, but also on the composition of the host fluid.

Objective

Adsorption of proteins on catheters exposed both ex vivo and in vitro to dialysate of patients on peritoneal dialysis (PD) was studied.

Methods

Peritoneal dialysis effluent was collected from 5 patients with end-stage renal disease on continuous ambulatory PD. Tenckhoff catheters were obtained from 16 patients. Deposition of proteins on excised Tenckhoff catheters and tubing of different materials exposed to PD effluent in vitro was studied using 125iodine-labeled antibodies. Adhesion of Staphylococcus aureus and Staphylococcus epidermidis strains was quantified on tubing exposed to PD effluent in vitro.

Results

The presence of albumin, transferrin, immunoglobulin G, fibrinogen, fibronectin, von Willebrand factor, vitronectin, and thrombospondin was determined at various concentrations in PD effluent. All proteins analyzed were detected on PD catheters removed from patients. The extent of protein deposition on Tenckhoff catheters exposed to PD effluent, in vitro, rapidly reached a plateau and remained constant, as it did on polyvinyl chloride and polyethylene tubing. Adhesion of staphylococci was enhanced on Tenckhoff catheters exposed to PD effluent compared to unused PD solution.

Conclusions

The data identify surface exposed proteins that may serve as adhesion sites for microbes on peritoneal catheters indwelled in patients undergoing PD.
Obesity is a Risk Factor for Peritonitis in the Australian and New Zealand Peritoneal Dialysis Patient Populations
Authors: McDonald Stephen P. , Collins John F. , Rumpsfeld Markus , Johnson David W.
Published: February 2020

Objective

The aim of the present investigation was to examine the association between body mass index (BMI) and peritonitis rates among incident peritoneal dialysis (PD) patients in a large cohort with long-term follow-up.

Design

Retrospective observational cohort study of the Australian and New Zealand PD patient population.

Setting

Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry.

Participants

The study included all incident adult patients ( n = 10 709) who received PD in Australia and New Zealand in the 12-year period between 1 April 1991 and 31 March 2003. Patients were classified as obese (BMI ≥ 30 kg/m2), overweight (BMI 25.0 – 29.9 kg/m2), normal weight (20 – 24.9 kg/m2), or underweight (< 20 kg/m2).

Main Measurements

Time to first peritonitis and episodes of peritonitis per patient-year were recorded over the 12-year period.

Results

Higher BMI was associated with a shorter time to first peritonitis episode, independent of other risk factors [hazard ratio 1.08 for each 5-kg/m2 increase in BMI, 95% confidence interval (CI) 1.04 – 1.12, p < 0.001]. When peritonitis outcomes were analyzed as episodes of peritonitis per patient-year, these rates were significantly higher among patients with higher BMI: underweight 0.69 episodes/year (95% CI 0.66 – 0.73), normal weight 0.79 (95% CI 0.77 – 0.81), overweight 0.88 (95% CI 0.85 – 0.90), obese 1.06 (95% CI 1.02 – 1.09). Coronary artery disease and chronic lung disease were associated with both shorter time to first peritonitis and higher peritonitis rates, independently of these other factors. There was also a “vintage effect,” with lower peritonitis rates seen among people who commenced dialysis in more recent years.

Conclusions

Higher BMI at the commencement of renal replacement therapy is a significant risk factor for peritonitis. The mechanisms for this remain undefined.
Changes in Causative Organisms and Their Antimicrobial Susceptibilities in Capd Peritonitis: A Single Center's Experience over one Decade
Authors: Kim Dong Ki , Yoo Tae-Hyun , Ryu Dong-Ryeol , Xu Zhong-Gao , Kim Hyun Jin , Choi Kyu Hun , Lee Ho Yung , Han Dae-Suk , Kang Shin-Wook
Published: February 2020

Background

In recent years, the rate of peritonitis during continuous ambulatory peritoneal dialysis (CAPD) has been significantly reduced. However, peritonitis remains a major complication of CAPD, accounting for considerable mortality and hospitalization among CAPD patients.

Objective

To generate a “center tailored” treatment protocol for CAPD peritonitis by examining the changes of causative organisms and their susceptibilities to antimicrobial agents over the past 10 years.

Method

Retrospective review of the medical records of 1015 CAPD patients (1108 episodes of peritonitis) who were followed up from 1992 through 2001.

Results

The overall incidence of peritonitis was 0.40 episodes/patient-year. The annual rate of peritonitis and the incidence of peritonitis caused by a single gram-positive organism were significantly higher in 1992 and 1993 compared with those in the rest of the years ( p < 0.05). The incidence of peritonitis due to coagulase-negative staphylococcus (CoNS) decreased significantly over time, whereas there was no significant change in the incidence of Staphylococcus aureus (SA)-induced peritonitis. Among CoNS, resistance to methicillin increased from 18.4% in 1992 – 1993 to 41.7% in 2000 – 2001 ( p < 0.05). In contrast, the incidence of methicillin-resistant SA was not different according to the calendar year. Catheter removal rates were significantly higher in peritonitis due to a single gram-negative organism (16.6%) compared with gram-positive peritonitis (4.8%, p < 0.005). The mortality associated with peritonitis was also higher in gram-negative (3.7%) compared with gram-positive peritonitis (1.4%), but there was no statistical significance. Among single gram-positive organism-induced peritonitis, catheter removal rates were significantly higher in SA (9.3%) than those in CoNS (2.9%, p < 0.01) and other gram-positive organisms (2.9%, p < 0.05). In peritonitis caused by CoNS, the methicillin-resistant group showed significantly higher removal rates than the methicillin-susceptible group (8.2% vs 1.0%, p < 0.01).

Conclusion

The incidence of peritonitis for 2001 decreased to less than half that for 1992, due mainly to a significant decrease in CoNS-induced peritonitis, whereas the proportions of peritonitis due to a single gram-negative organism and methicillin-resistant CoNS increased. These findings suggest that it is necessary to prepare new center-based guidelines for the initial empirical treatment of CAPD peritonitis.
Vancomycin and Ciprofloxacin: Systemic Antibiotic Administration for Peritoneal Dialysis-Associated Peritonitis
Authors: Goffin Eric , Herbiet Laurence , Pouthier Dominique , Pochet Jean-Michel , Lafontaine Jean-Jacques , Christophe Jean-Louis , Gigi Jacques , Vandercam Bernard
Published: February 2020

Objectives

Peritonitis due to peritoneal dialysis (PD) is best treated empirically while waiting for the results of the dialysate culture. Thus, antibiotic therapy must cover both gram-positive and gram-negative micro-organisms. First, over a period of 9 years in a multicenter study we evaluated the efficiency of a vancomycin and ciprofloxacin combination given as the first-line treatment protocol for PD peritonitis. Second, we evaluated whether a systemic route of administration of the antibiotics could be an interesting alternative to the usual cumbersome intraperitoneal drug administration.

Methods

Vancomycin 15 mg/kg body weight, intravenous, and oral ciprofloxacin 250 mg two times per day (500 mg twice per day if residual creatinine clearance was above 3 mL/minute) were prescribed at diagnosis of peritonitis. Vancomycin injections were repeated (when blood trough level was expected to be below 12 μg/mL) in cases of gram-positive organisms for a total duration of 3 weeks. Ciprofloxacin was given for a total of 3 weeks in cases of gram-negative and a total of 10 days for susceptible gram-positive infections.

Results

A total of 129 episodes of peritonitis occurred; 28 of them were not included in the study because of protocol violation ( n = 15) or fungal ( n = 7) or fecal ( n = 6) peritonitis, leaving 101 peritonitis episodes for analysis. 52 (51.5%) gram-positive and 28 (27.7%) gram-negative organisms were grown; 38 gram-positive organisms were coagulase-negative staphylococci. No organism was identified in 8 peritonitis episodes, whereas 13 peritonitis episodes were caused by more than 1 organism. 35% of the coagulase-negative staphylococci were resistant to first-generation cephalosporin and methicillin, whereas all were susceptible to vancomycin. For gram-negative bacilli, the susceptibility rate was 96% and 95% for ciprofloxacin and ceftazidime respectively. The overall treatment success rate was 77.2% (78 of the 101 peritonitis episodes): 61.4% at first intention and 15.8% after optimization of the antibiotic therapy (second intention). The protocol failed in 22.8% of the peritonitis episodes. Hospitalization was required in 52% of the peritonitis episodes; average hospitalization was 11 (range 1 – 45) days.

Conclusion

Systemic vancomycin and ciprofloxacin administration is a simple and efficient first-line protocol antibiotic therapy for PD peritonitis. In our opinion, vancomycin should still be used for gram-positive infections because of its high susceptibility rate compared with first-generation cephalosporins, providing a close monitoring of the local epidemiology. Oral ciprofloxacin provides satisfactory results in gram-negative infections, comparable to those obtained with intraperitoneal ceftazidime or aminoglycosides.
Retroperitoneal Leakage as a Cause of Ultrafiltration Failure
Authors: Lam Man-Fai , Lo Wai-Kei , Chu Ferdinand S.K. , Li Fu-Keung , Yip Terence P.S. , Tse Kai-Chung , Chan Tak-Mao , Lai Kar-Neng
Published: February 2020

We report 3 patients on continuous ambulatory peritoneal dialysis (CAPD) who developed reversible ultrafiltration failure secondary to retroperitoneal leakage. The patients presented with pulmonary edema and fluid overload following a sudden onset of ultrafiltration failure on maintenance CAPD. There was no localized edema, suggesting peritoneal leakage in the abdominal wall or the perineum. Radiological examination showed no migration of the Tenckhoff catheter. Leakage of dialysate into the retroperitoneal space was only revealed by computed tomographic (CT) peritoneography. These patients were then treated with intermittent peritoneal dialysis twice weekly. After repeated CT peritoneography showing complete resolution of the leakage, they successfully resumed CAPD treatment 2 months later, without ultrafiltration problems. Our finding suggests that retroperitoneal leakage could be one of the uncommon, yet reversible, causes of acute ultrafiltration failure that can be diagnosed with CT peritoneography.
Bleeding Complications Associated with Peritoneal Dialysis Catheter Insertion
Authors: Mital Sangeeta , Fried Linda F. , Piraino Beth
Published: February 2020

Objective

To identify the incidence of bleeding complications associated with peritoneal dialysis catheter insertion.

Design

Retrospective review at a tertiary-care center of all double-cuffed Tenckhoff catheters placed surgically from 1 January 1992 to 1 October 2003 to identify the incidence of major bleeding complications occurring with catheter insertion. Major bleeding episodes were defined as ≥ 3% decline in hematocrit, or the need for surgical intervention or blood transfusion within 2 weeks of insertion.

Results

292 catheters had been inserted in 263 patients. Six patients satisfied the criteria for a major bleeding event, for a major bleeding complication rate of 2%. Bleeding was associated with perioperative anticoagulation in 3 patients, uremia and thrombocytopenia in 1 patient, aspirin use and thrombocytopenia in 1 patient, and 1 patient experienced intraoperative bleeding. Coagulation parameters were not obtained prior to the procedure in 2 of the 6 patients.

Conclusion

The rate of serious bleeding complications related to catheter insertion is low and usually associated with anticoagulation. Holding anticoagulation therapy for a minimum of 24 hours during the postoperative period should eliminate much of the risk. Coagulation parameters should also be obtained and corrected preoperatively.
Bimodal Dialysis: An Integrated Approach to Renal Replacement Therapy
Authors: McIntyre Christopher W.
Published: February 2020

Background

Peritoneal dialysis (PD) and hemodialysis (HD) are both widely used as sole therapies for end-stage renal disease (ESRD). There is still controversy over which (if either) is superior in terms of patient outcomes. Peritoneal dialysis offers the advantages of long, slow, continuous ultrafiltration and potentially enhanced protection of residual renal function (RRF). In contrast, HD offers superior solute removal at the cost of undesirable cardiovascular tolerance of high rates of sodium and water removal. The aim of this study was to investigate the clinical feasibility of offering a combined treatment of both modalities [bimodal dialysis (BMD)] to incident patients reaching ESRD. We set out to investigate if it might be possible to utilize the intrinsic advantages of both modalities within a setting of good patient acceptability.

Methods

We prospectively studied 8 patients. They were recruited in the pre-ESRD phase from a specialist low clearance clinic. An arteriovenous fistula was formed and peritoneal catheters were inserted. The BMD consisted of 2, 3-hour, high efficiency, euvolemic HD sessions per week in combination with 2 PD exchanges per day to provide a degree of solute clearance and all of the ultrafiltration. Adequacy was measured independently for each modality. Patients were followed using the standard range of evaluations in addition to RRF (by creatinine clearance and EDTA clearance), echocardiography (left ventricular mass and ventricular performance), treatment outcomes, patient symptoms, and complications.

Results

Mean time on BMD was 346 ± 74.9 (range 245 – 431) days. Peritonitis rate was 21 months per episode (mean 0.6 ± 0.9, 0 – 2 episodes per patient). Mean peritoneal ultrafiltration volume was 1.58 ± 0.32 (1.3 – 2.1) L per day. Delivered Kt/V and weekly PD Kt/V did not change significantly. Patients’ RRF was maintained over the study period, as were serum albumin and control of serum phosphorus. Blood pressure was controlled with a reduction in the number of antihypertensive agents. Left ventricular mass index reduced over the treatment period, from a mean of 194 ± 31.2 (161 – 265) to 156 ± 21.2 (138 – 189) g/m2 ( p = 0.05). Ventricular performance remained unchanged over the study [ejection fraction 50.4 ± 11.1 (38 – 67) % to 48 ± 8.0 (48 – 67) %]. Mean time during BMD spent on HD alone was 4.2 ± 6.9 (0 – 16) days, and on PD alone 9.2 ± 10.6 (0 – 25) days.

Conclusion

This study suggests that BMD is a feasible treatment for ESRD. It is associated with adequate solute removal and good hemodynamic/volume control, and allows increased treatment flexibility for coping with complications normally requiring recourse to unplanned HD with temporary central venous access.
Sterile Peritonitis in the Peritoneal Dialysis Patient
Authors: de Freitas Declan G. , Gokal Ram
Published: February 2020

Peritonitis is a serious and common problem in the peritoneal dialysis (PD) population. Abdominal pain, fever, and cloudy PD fluid usually heralds the onset of infective peritonitis. However, in up to 20% of cases, no organism is identified. In these situations, diagnosis can be made only by excluding a microbiological cause and performing a cytological examination of the PD fluid to determine the cellular or noncellular constituents. This review examines the differential diagnosis of sterile peritonitis and uses cytological examination to facilitate the appropriate diagnosis.
Randomized, Open Label, Controlled Clinical Trial of Oral Administration of an Egg Albumin-Based Protein Supplement to Patients on Continuous Ambulatory Peritoneal Dialysis
Authors: González-Espinoza Liliana , Gutiérrez-Chávez Jorge , del Campo Fabiola Martín , Martínez-Ramírez Héctor R. , Cortés-Sanabria Laura , Rojas-Campos Enrique , Cueto-Manzano Alfonso M.
Published: February 2020

Background/Aim

Malnutrition is highly prevalent in patients on continuous ambulatory peritoneal dialysis (CAPD) and is a strong predictor of increased morbidity and mortality. Therefore, the aim of this study was to evaluate the effect of oral administration of an egg albumin-based protein supplement on the nutritional status of CAPD patients.

Methods

In this randomized, open label, controlled clinical trial, 28 CAPD patients were allocated to a study ( n = 13) or a control ( n = 15) group. Both groups received conventional nutritional counseling; the study group received, additionally, an oral egg albumin-based supplement. During a 6-month follow-up, all patients had monthly clinical and biochemical evaluations and quarterly assessments of adequacy of dialysis and nutrition.

Results

Serum albumin levels were not different between groups; however, a significant increase (baseline vs final) was observed in the study group (2.64 ± 0.35 vs 3.05 ± 0.72 g/dL) but not in the control group (2.66 ± 0.56 vs 2.80 ± 0.54 mg/dL). Calorie and protein intake increased more in the study group (calories 1331 ± 432 vs 1872 ± 698 kcal; proteins 1.0 ± 0.3 vs 1.7 ± 0.7 g/kg) than in the control group (calories 1423 ± 410 vs 1567 ± 381 kcal; proteins 1.0 ± 0.4 vs 1.0 ± 0.3 g/kg). Similarly, non-protein nitrogen appearance rate (nPNA) increased significantly more in the study (1.00 ± 0.23 vs 1.18 ± 0.35 g/kg/day) than in the control group (0.91 ± 0.11 vs 0.97 ± 0.14 g/kg/day). Triceps skinfold thickness (TSF) and midarm muscle area (MAMA) displayed a nonsignificant trend to a greater increase in the study group (TSF 16.7 ± 8.7 vs 18.3 ± 10.7 mm; MAMA 23.8 ± 6.2 vs 25.8 ± 5.9 cm2) than in controls (TSF 16.4 ± 5.7 vs 16.9 ± 7.0 mm; MAMA 28.7 ± 7.8 vs 30.0 ± 7.9 cm2). At the end of follow-up, the frequency of patients with moderate or severe malnutrition decreased 6% in the control group and decreased 28% in the study group. At the final evaluation, the most important predictors of serum albumin were the oral egg albumin-based supplement administration and protein intake ( p < 0.05); secondary predictors ( p = 0.06) were peritoneal transport rate and MAMA.

Conclusions

In the study group, oral administration of the egg albumin-based supplement significantly improved serum albumin, calorie and protein intake, and nPNA, and, compared to controls, this maneuver was associated with a trend to increased anthropometric parameters and improved Subjective Global Assessment evaluation. Oral administration of the albumin supplement and protein intake were the most significant predictors of serum albumin at the end of follow-up. This oral supplement may be a safe, effective, and cheap method to improve nutritional status in peritoneal dialysis patients.
Peritonitis-Related Mortality in Patients Undergoing Chronic Peritoneal Dialysis
Authors: Fontán Miguel Pérez , Rodríguez-Carmona Ana , García-Naveiro Rafael , Rosales Miguel , Villaverde Pedro , Valdés Francisco
Published: February 2020

Peritonitis is a well-known cause of mortality in peritoneal dialysis (PD) patients. We carried out a retrospective study to disclose the clinical spectrum and risk profile of peritonitis-related mortality. We analyzed 693 episodes of infectious peritonitis suffered by 565 patients (follow-up 1149 patient-years). Death was the final outcome in 41 cases (5.9% of episodes), peritonitis being directly implicated in 15.2% of the global mortality and 68.5% of the infectious mortality observed. In 41.5% of patients with peritonitis-related mortality, the immediate cause of death was a cardiovascular event. Highest mortality rates corresponded to fungal (27.5%), enteric (19.3%), and Staphylococcus aureus (15.2%) peritonitis. Multivariate analysis disclosed that the baseline risk of peritonitis-related mortality was significantly higher in female [relative risk (RR) 2.13, 95% confidence interval (CI) 1.24 – 4.09, p = 0.02], older (RR 1.10/year, CI 1.06 – 1.14, p < 0.0005), and malnourished patients (RR 2.51, CI 1.21 – 5.23, p = 0.01) with high serum C-reactive protein (s-CRP) levels (RR 4.04, CI 1.45 – 11.32, p = 0.008) and a low glomerular filtration rate (RR 0.75 per mL/minute, CI 0.64 – 0.87, p < 0.0005). Analysis of risk after a single episode of peritonitis and/or subanalysis restricted to peritonitis caused by more aggressive micro-organisms disclosed that overall comorbidity [odds ratio (OR) 1.21, CI 1.05 – 1.71, p = 0.005], depression (OR 2.35, CI 1.14 – 4.84, p = 0.02), and time on PD at the time of the event (OR 1.02/month, CI 1.00 – 1.03, p = 0.02) were other predictors of mortality.

In summary, the etiologic agent is a definite marker of peritonitis-related mortality but gender, age, residual renal function, inflammation (s-CRP), malnutrition, and depression are other significant correlates of this outcome. Most of these risk factors are common to cardiovascular and peritonitis-related mortality, which may explain the high incidence of cardiovascular event as the immediate cause of death in patients with peritonitis-related mortality.
Biocompatibility of a Bicarbonate/Lactate-Buffered PD Fluid Tested with a Double-Chamber Cell Culture System
Authors: Fusshoeller Andreas , Baehr Jessica , Grabensee Bernd , Plum Joerg
Published: February 2020

Objective

In peritoneal dialysis (PD), neutrally buffered PD fluids with lower concentrations of glucose degradation products (GDP) have tested superior to conventional fluids in terms of biocompatibility. However, conventional in vitro studies provoke debate because, due to the lack of subsequent equilibration with the blood, they do not resemble the true intraperitoneal situation of PD.

Methods

We established a double-chamber cell culture system with peritoneal mesothelial cells seeded on top of a permeable membrane, with a physiological buffer below. Thus adequately reflecting the in vivo equilibration pattern, we compared a conventional fluid with a neutral bicarbonate/lactate-buffered PD solution. Using an exchange pattern adapted from an 8-hour continuous ambulatory PD regimen, cell viability was assessed with an MTT assay, and cell function via constitutive and stimulated interleukin (IL)-6 release. As an indicator of potential induction of fibrosis and as a parameter of mesothelial cell integrity, respectively, transforming growth factor-beta 1 (TGF-β1) generation and cancer antigen 125 (CA125) release were measured.

Results

The conventional solution significantly compromised mesothelial cell viability and function in terms of mitochondrial activity ( p < 0.05) and stimulated IL-6 release ( p < 0.05). The bicarbonate/lactate fluid had no effect on cell viability or IL-6 release and turned out to be equivalent to the properties of the growth medium. Whereas lactate-incubated cells did not respond to IL-1β stimulation, bicarbonate/lactate-treated cells adequately increased IL-6 release after stimulation ( p < 0.0005). Release of TGF-β1 and CA125 did not differ between the different fluids and the control.

Conclusions

Due to the sustained equilibration process, the double-chamber cell culture model allows a more realistic insight into mesothelial cell viability and function in terms of PD. As in classic in vitro studies, an adverse effect of conventional PD solutions on mesothelial cells was overt in the present cell culture system. The neutral bicarbonate/lactate-buffered fluid with low GDP content, however, did not interfere with mesothelial cell vitality or function, indicating superior biocompatibility.
TGF-β1 Induced by High Glucose is Controlled by Angiotensin-Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker on Cultured Human Peritoneal Mesothelial Cells
Authors: Kyuden Yasufumi , Ito Takafumi , Masaki Takao , Yorioka Noriaki , Kohno Nobuoki
Published: February 2020

Background

Loss of peritoneal function is a major complication associated with long-term peritoneal dialysis. Observed changes include loss and degeneration of the mesothelium, submesothelial thickening, alterations in the structure and number of blood vessels, and reduplication of the vascular basement membrane. Exposure to high glucose concentrations in peritoneal dialysis solutions is known to cause injury to cultured human peritoneal mesothelial cells (HPMC) as a result of overexpression of transforming growth factor beta 1 (TGF-β1). Previous studies have demonstrated that angiotensin II (AII) increases expression of TGF-β1 in a number of different cell types; although this has not been demonstrated in HPMC.

Objective

To clarify possible mechanisms involved in peritoneal fibrosis, we investigated whether HPMC expressed AII-forming pathway mRNA and whether increases in AII induced by high glucose contribute to the production of TGF-β1. We also examined the effects of the angiotensin-converting enzyme inhibitor (ACEI) perindoprilat and the AII receptor blocker (ARB) candesartan on expression of TGF-β1 and proliferation of HPMC.

Methods

Expression of mRNA for the AII-forming pathway and TGF-β1 in HPMC was examined by reverse transcriptase-polymerase chain reaction (RT-PCR) and quantitative RT-PCR. Levels of AII and TGF-β1 following 48 hours of incubation of the cells in a range of glucose concentrations were measured by enzyme immunoassay and enzyme linked immunosorbent assay respectively. The effect of glucose on cell proliferation was examined using the water-soluble tetrazolium salt WST-1 and [3H]-thymidine uptake. We also investigated the effect of ACEI and ARB on the expression of TGF-β1 and the proliferation of HPMC incubated at high glucose for 48 hours.

Results

AII-forming pathway mRNA was detected in HPMC, with expression of angiotensinogen, angiotensin-converting enzyme (ACE), AII type 1 receptor, and TGF-β1 mRNA increasing following exposure to glucose according to glucose concentration. High glucose was also shown to increase the production of AII and TGF-β1 and decrease the proliferation of HPMC. In contrast, we found that both the ACEI and the ARB attenuated the increase in TGF-β1 production and reduced cell proliferation caused by exposure to high glucose. These effects were greater with a combination of the two drugs.

Conclusion

The present study provides evidence that ( 1 ) HPMC express mRNA for the AII-forming pathway; ( 2 ) ACEI and ARB inhibit the TGF-β1 production induced by high glucose; ( 3 ) the AII-forming pathway is one mechanism by which high glucose causes production of TGF-β1. In addition to having antihypertensive and renal-protective effects, combination therapy with an ACEI and an ARB may also be effective in preventing loss of peritoneal function and decreasing peritoneal fibrosis.
Efficient Monthly Subcutaneous Administration of Darbepoetin in Stable CAPD Patients
Authors: Theodoridis Marios , Passadakis Ploumis , Kriki Pelagia , Panagoutsos Stelios , Yannatos Evangelos , Kantartzi Konstantia , Sivridis Dimitris , Vargemezis Vasilis
Published: February 2020

Background

Although subcutaneous administration of recombinant human erythropoietin (rHuEPO) in continuous ambulatory peritoneal dialysis (CAPD) patients is a widely accepted recommendation, the lowest possible frequency of an efficient dosing regimen remains controversial. Darbepoetin alpha, a new erythropoiesis-stimulating protein with a threefold longer serum half-life compared with rHuEPO, has greater in vivo potency and can be administered less frequently to obtain the same biological response. This study assessed the efficacy of darbepoetin administered once monthly in the treatment of anemia in CAPD patients.

Patients and Methods

In this single-center, prospective cohort study, 11 stable CAPD patients (5 males, 6 females; mean age 68.8 ± 14.1 years; mean duration on peritoneal dialysis 31.6 ± 13 months) maintained average hemoglobin and hematocrit levels of 12.09 ± 1.29 g/dL and 37.29% ± 3.58%, respectively, while receiving a mean weekly maintenance dose of epoetin alfa of 129 IU/kg. These same patients were assigned to receive the equivalent weekly darbepoetin dose once monthly for 24 consecutive weeks. Hematological response, iron status (transferrin saturation, serum ferritin levels), C-reactive protein (CRP), and the patients’ biochemical profiles were evaluated monthly.

Results

During the monthly administration of darbepoetin, mean serum levels of Hb and Hct were 12.17 ± 1.28 g/dL and 37.1% ± 1.19% respectively. No statistically significant difference was apparent between the previous and monthly dosing values (12.09 ± 1.29 vs 12.17 ± 1.28 g/dL, p = 0.769, and 37.29% ± 3.58% vs 37.1% ± 1.19%, p = 0.752). Transferrin saturation levels as well as serum ferritin levels also remained unchanged (30.4% ± 8.6% vs 30.1% ± 9.4%, NS, and 556 ± 212 vs 621 ± 234 ng/mL, respectively, NS).

Conclusion

These results indicate that darbepoetin alfa can be effectively given subcutaneously at monthly intervals for the treatment of anemia in stable CAPD patients. However, more studies are needed to validate the long-term efficacy of this monthly subcutaneous administration.