Relationship between peritonitis and exit site infections in CAPD. This study was designed to retrospectively review the experience in this center with oral ciprofloxacin 500 mg bid and ip vancomycin 25 mg/L in the treatment of CAPD-related exit site infections and to determine the relationship between exit site infections and peritonitis. There were 48 patients with 172 episodes of infection (23 had both infections, 22 had peritonitis only, 3 had exit site infections only). Thus, exit site infections occur infrequently in the absence of peritonitis (23% of occasions). Of the 35 patients who had peritonitis as the first infection, 13 (37%) subsequently developed an exit site infection. The mean +/- SD period from an initial peritonitis to a subsequent exit site infection in these patients was 8.2 +/- 8.0 (range 1-28) months. Of the 22 patients with 34 exit site infections, there were 15 (44%) treatment failures, of which 10 (67%) were relapses or possible relapses. S. aureus was the most common isolate. 5% of exit site infections were culture negative. Follow-up was incomplete for many patients resulting in many instances of no further cultures, and compliance could not be assured. This combination was associated with a high incidence of treatment failures in this setting.


Erythema: does it indicate infection in a peritoneal catheter exit site? The definition of a peritoneal catheter exit site infection varies from one dialysis center to another. A review of abnormal appearing exit sites (n = 334 in 169 patients) from 1/83 to 3/91 was done to compare outcome in exit sites presenting with erythema (39, 12%) to those with drainage plus erythema (72, 22%) or drainage alone (223, 67%). Resolution of the abnormality occurred in 48% of those exit sites with drainage, 62% with erythema and drainage, and 79% with erythema alone (p < 0.005). S. aureus was present in 62% of the cultured exit sites which had erythema alone, 64% with erythema plus drainage, and 41% with drainage alone, while Gram negative rods were present in 13%, 12%, and 35%, respectively (p < 0.005). Twenty-three of the 39 exit sites with erythema were not initially treated with antibiotics; 87% resolved compared with 69% of those treated immediately with antibiotics (p = ns). Seven of the 8 erythematous exit sites that did not resolve progressed to tunnel infection and/or peritonitis and required catheter removal, despite the addition of antibiotics in the three initially untreated. Six of the 8 unresolved erythematous exit sites were due to S. aureus. These results indicate that, although drainage is the commonest exit site abnormality and has the worst prognosis, peri-catheter erythema is not always benign, representing an early sign of infection in some cases.


Imipenem versus netilmicin and vancomycin in the treatment of CAPD peritonitis. Imipenem/cilastatin is a new thienamycin antibiotic with a broad bactericidal spectrum. We undertook a prospective randomised study to compare the safety and efficacy of intraperitoneal (IP) imipenem/cilastatin (2 gm daily) [group A; 21 patients, mean age 49.2 years] with a combination of IP netilmicin and vancomycin (500 and 60-100 mg daily resp.) [group B; 20 patients, mean age 55.2 years] in CAPD peritonitis. Each patient underwent 4 daily CAPD exchanges with antibiotics in alternate exchanges. The causative organisms were similar in both the groups as was the duration of therapy (gr.A: 6.8 +/- 0.27 days; gr.B: 7.2 +/- 0.51 days; p = NS). Complete cure was marginally better with imipenem/cilastatin (gr.A; 94.1%, gr.B: 83.3%) with less relapses (gr.A: 1 episode; gr.B: 3 episodes). One episode in gr.A (S. aureus) and 2 in gr.B (Yeast & Proteus) failed to resolve and required catheter removal. Two gr. A patients developed generalised convulsions which settled after discontinuation of the drug. Whilst the results show no significant difference in the outcome in the two groups, the use of IP imipenem would offer a possible advantage as a single antibiotic. Larger experience is needed before imipenem can be recommended as a 'blind' first line agent for CAPD peritonitis.


Treatment of Staphylococcus aureus nasal carriers in CAPD with mupirocin. We have studied the efficacy of topical Mupirocin for elimination of Staphylococcus aureus (Staph. aureus) nasal carriage in CAPD patients. Staph. aureus nasal carriers in our CAPD program were randomized to one of two groups: Group 1, treated with Mupirocin, and Group 2, treated with neomycin sulphate nasal ointment. The prevalence of Staph. aureus nasal colonization was 44% for patients (24/54) and 17% for dialysis partners (5/29). Group 1 included 11 patients and 1 partner, and Group 2, 8 patients and 2 partners. In Group 1, the eradication rate was 100%, and the recolonization rate was 0, 8, 41, 55 and 66% at 1, 2, 3, 6 and 10 months. In Group 2, the eradication rate was 40%, with a recolonization rate of 0.25 and 75% at 1, 2 and 3 months. Re-treatment with mupirocin was successful in 66% of the cases, compared to 20% for neomycin. The MIC90 of mupirocin for Staph. aureus was 0.5 mcg/mL, with an increase to 4 mcg/mL towards the end of the study. During the study period, there was a very low incidence of Staph. aureus peritonitis or catheter-related infections in patients treated with mupirocin. Secondary effects of mupirocin were negligible. Mupirocin is more effective than neomycin sulphate for the elimination of Staph. aureus nasal colonization in patients undergoing CAPD. Periodic re-treatment is frequently necessary, given the significant recolonization rate.


Treatment of CAPD peritonitis with clavulanate potentiated ticarcillin. A total of 16 episodes of peritonitis in 14 patients (9 males, 5 females), were treated with Clavulanate potentiated ticarcillin (TC), a -lactamase stable parenteral penicillin. All the pts were hospitalized and received initial loading dose of 3.2 gr intraperitoneally (i.p.) in a 6-hour 1 L exchange, which was followed by four 1 L exchanges with 320 mg/LTC. The therapy was continued for ten days. The bacteria isolated were: Staph. epid. (4), Staph. aureus (2), Strept. viridans (1), Enterococcus (1), Klebsiella Pneum. (1), Serratia (1), Enterobacter (1), Pseudomonas species: stutszeri (2), cepacia (1), fluorescens (1), negative cultures (1). Recurrence of peritonitis was seen in three patients with Pseudomonas (stutszeri (2), fluorescens (1)) peritonitis, 10-16 days after cessation of therapy. No clinical or biological side effects were seen in any patient during and/or after the therapy. These results suggest that, i.p. monotherapy of TC is effective in the treatment of CAPD peritonitis, while in cases of Pseudomonas peritonitis more specific regimens should be used.


The modulation by fresh and spent peritoneal dialysis fluids of antibiotic kinetics directed against Staphylococcus epidermidis biofilms. The presence of CAPD peritoneal catheters has an association with S. epidermidis infections which are relatively resistant to antibiotic therapy. This resistance has been ascribed to the formation by the bacteria of a protective matrix on the catheter surface enclosing the bacteria to form a bacterial biofilm. The rate of action of 14 antibiotics on standardized S. epidermidis bacterial biofilms over a 5 day exposure period and the modifying effects of fresh and spent peritoneal dialysis fluids were assayed. There were significant differences in the rates of antibiotic action. Fresh dialysis solution markedly augmented rifampin activity, and to a lesser extent, vancomycin, cloxacillin and teicoplanin but antagonized ciprofloxacin. Spent dialysis fluid generally augmented the activity of antibiotics, notably cloxacillin and cephalothin. Rifampin was bactericidal in both fresh and spent dialysis fluids. Fusidic acid was a poor performer in all tests.


Peritonitis and the patient with human immunodeficiency virus (HIV). The prevalence of HIV positive patients (HIV pts) with ESRD is likely to increase and many will be going on CAPD. There are, however, factors which cause one to be concerned about a possible increased risk of peritonitis in these patients. These include not only their impaired immune and nutritional status, but often their mental status. We examined the incidence and type of peritonitis among the 184 patients who have been in our program since December 1983 for a total of 4,017 patient months (pt mo). During this time we treated 9 known HIV pts (4 drug users and 5 homosexuals) for a total of 114 pt mos. We also looked at albumin, cholesterol, and creatinine as possible risk markers. We found a greater than two fold incidence of peritonitis in the HIV positive patients and that low albumin was a significant risk factor in the HIV negative patients, but not in the HIV positive patients.


Staphylococcus aureus nasal carrier status (SANCS) in CAPD patients; is it induced or favored by subcutaneous rHu-erythropoietin? Staphylococcus aureus nasal carriage status (SANCS) has been recognized as a risk factor for patients on CAPD, due to a higher probability of suffering peritoneal catheter infections. The use of subcutaneous drugs (insulin dependent diabetics, drug addicts, HD patients and antiallergic vaccines), has been associated with increased risk of SANCS. On CAPD, erythropoietin (EPO) is almost universally used by the subcutaneous route. The objective of this paper was to evaluate the incidence and prevalence of SANCS in 85 CAPD patients by means of nasal smear and the influence of SANCS on peritoneal and catheter infection rate. Patients were divided in four groups according to diabetic status and EPO treatment (mean dose 2000 u. twice a week). The prevalence of SANCS in control groups was 30% in non-diabetics and 23% in diabetics. EPO treated patients showed a prevalence of SANCS of 39% in non-diabetics and 45% in diabetics due to the presence of 7 and 5 carrier patients respectively. SANCS patients (29% of the population), suffered 45% of peritonitis and 42% of exit-site infections caused by S. aureus. In a prospective part of the study, there was no difference in the frequency of developing positive cultures among EPO and control (30% of patients). No male EPO treated patients developed SANCS. We conclude that it is necessary to monitor S. aureus nasal carrier status periodically in CAPD patients especially in women. Whether or not subcutaneous erythropoietin treatment is implicated pathogenetically with SANCS, is not clarified by our data because of the frequent spontaneous appearance of SANCS among CAPD patients.(ABSTRACT TRUNCATED AT 250 WORDS)


Detection of CMV-DNA in cells from peritoneal fluid of IPD/CAPD patients by polymerase chain reaction. Documented viral peritonitis in peritoneal dialysis patients is rare, although up to 20% of all cases are culture negative (non-fungal, non-bacterial). CMV-infected peritoneal cells may serve as a reservoir for reinfection and/or reactivation of CMV after renal transplantation. CMV-Polymerase Chain Reaction (CMV-PCR) amplification analysis identified CMV-DNA in cells from the peritoneal dialysate of 8 patients (3 culture negative peritonitis from a total of 5 examined) and 5 asymptomatics) out of 17 potential kidney transplant recipients (6 on IPD 16.6 +/- 6 months, range 10-29 months; 11 on CAPD 28.1 +/- 25 months, range 2-81 months). Serum titers (10/17 patients analyzed) of anti-CMV IgG antibodies ranged from < 1:20 to 1:320 (no correlation with CMV-DNA) while anti-CMV IgM antibodies were undetectable. Detection of CMV specific sequences in peritoneal cells in peritoneal dialysis patients by the PCR assay is sensitive (amplification of a 133 bp immediate early CMV gene sequence allows detection of 10 CMV infected cells in a background of 10(5) uninfected peritoneal cells), rapid (1 day visual, 3 days with confirmation by Southern hybridization), specific (no amplification of human embryo and kidney cell DNA, or HSV, EBV, or VZV infected cells) and is non-invasive in IPD/CAPD patients since no additional invasive technique is required.


Peritoneal clearances of carbon dioxide in the rat. In our previous rat studies (Kidney Int. 1991; 39: 608-617) we evaluated peritoneal clearances (Cp) representing near exclusively diffusive CO2 transfer: for isosmotic (0.37% dextrose) and hyperosmotic (15% dextrose) solutions with pH 7.2-7.3, CpCO2 were 1.20 +/- 0.08 and 1.84 +/- 0.04 ml/min, respectively. In the present studies we have compared Cp of CO2 gas and HCO3- in anesthetized rats (n = 22) using solutions with dextrose contents as mentioned above but with pH 6.5 or 7.6; we have also evaluated how much Cp CO2 measurements obtained with solutions at these pH values differ from Cp shown earlier with the solutions of pH 7.2-7.3. Cp of CO2 gas and HCO3- were significantly higher under hyperosmotic than isosmotic conditions. The use of solutions of pH different from 7.2-7.3 resulted in higher Cp of CO2 gas: with isosmotic solutions of pH 6.5 and 7.6 mean increases were 25 and 75%, respectively; with hyperosmotic solutions respective increases were 45 and 134%. We conclude that dialysis solution osmolality and pH significantly change Cp of CO2 gas and HCO3- in the rat. For evaluation of peritoneal blood flow from diffusive transfer parameters of CO2 gas, smaller overestimation can be expected when dialysis solution pH is slightly under-than overadjusted compared to blood pH.


Does catheter immobilization reduce exit-site infections in CAPD patients? This study was undertaken to ascertain the effectiveness of an immobilization device in reducing exit site infections (ESI) in CAPD patients, and whether immuno-suppressive therapy, diabetes, disconnect system and Staphylococcus aureus nasal carriage had any bearing on the incidence of ESI. Sixty-six patients having a Tenckhoff catheter placement were randomly allocated into one of three groups; immobilizer, tape and non-immobilized group. The groups were monitored for the incidence of ESI over a total period of 347 patient months. The results show no significant difference in infection rates between the three groups, nor do the factors mentioned have any bearing on ESI rate. Whilst immobilization is important, the ineffectiveness of this device was probably related to its design problem.


The impact of peritonitis on CAPD results. The impact of peritonitis on CAPD results was evaluated in 1990 pts (mean age +/- SD:58.4 +/- 14.8 yrs, 55.9% males), treated in 30 centres participating in Italian PD Study Group, during 1980-89, with an overall observation period of 3953 years (mean +/- SD 24.1 +/- 22.3 months). The incidence of peritonitis decreases from 1.21 (1980-84) to 0.48 (1985-89) ep/year (overall:0.68) with a significant (P < 0.001) reduction of the probability of developing the first peritonitis episode (FPE) through the same periods. The probability of developing FPE and the relative risk of peritonitis were significantly lower (P < 0.001) in pts for whom CAPD has been the first treatment (80.1%); on the contrary these parameters did not gain significant difference according to sex, age 65 years, diabetes or cardiovascular disease. As far as the organisms responsible for peritonitis are concerned a significant reduction of S. epid. and an increase of S. aureus, other Gram pos. and Pseudomonas was observed in the second 5-yr periods. Peritonitis episodes caused catheter removal in 8.2% of cases and were associated with catheter infection in 10.8% of cases. Peritonitis accounted for 24.2% of hospitalization causes and for 6.7% and 30.0% of death and of drop-out respectively. The probability of death and drop-out was significantly high (p < 0.001) in pts with a peritonitis incidence > 1 ep/year than in those with < 0.5 ep/year. The probability of drop-out due to peritonitis was not higher in diabetic or older patients.


CAPD bag changing with integrated disconnect system gives lower incidence of peritonitis than with UV-box system. The use of a UV-box disconnect system reduces the incidence of peritonitis as compared with manual exchanges. An integrated disconnect system (IDS) also gives good results. See Figure 1. From 1988-1991, we prospectively compared two groups of patients using either a UV-box disconnect system (Baxter, n = 18, mean age 64, range 28-75 yrs) or an IDS (Baxter, n = 25, mean age 53, range 30-78). The Tenckhoff catheter had been inserted by the same technique in all patients, and the training program and nursing care were also identical. Since many younger patients preferred IDS and refused randomization, age was significantly lower in the IDS group. All peritonitis episodes (PER) were registered. Excluded from calculations of PER were episodes most probably not due to failure in connective device: PER after incidental penetration of the dialysis bags, deep penetrating tunnel infections and in the direct course of abdominal surgery. There were significantly fewer months with PER (one month = 1 PER; Chi-2 = 6.45, p < 0.05) in patients using the IDS (3 PER/269 months) compared with those using the UV-box system (15 PER/355 months). The IDS was requested mainly by younger patients, while some older patients found it to be too complicated. The integrated disconnect system is especially acceptable by younger patients, and patients using the IDS show a low incidence of peritonitis.


A new catheter to prevent exit-site infection in peritoneal dialysis. In order to prevent exit-site infection, we studied a new Tenckhoff-derived catheter, named the "Malpighi catheter," capable of avoiding sinus tract formation. The outer cuff of this new device is 3.5 cm long and is deliberately positioned half-extruded; in fact, half of the cuff remains outside the skin exit-site. The implantation technique is identical to that of the standard two-cuff Tenckhoff catheter. We implanted eight Malpighi catheters in 5 CAPD and 3 IPD patients. The observation period was 146 patient-months (range 14-23, M +/- SD 18.2 +/- 3.3). We observed excellent adhesion between the outer cuff and surrounding tissue. Actually, by pulling the catheter the skin around the half-extruded cuff becomes cone-shaped, with the cone's apex tightly stuck to cuff and the sinus tract disappearing completely. Only one case of exit-site infection by Staphylococcus aureus and two cases of ulcer of the skin beneath the external part of the half-extruded cuff were observed. These complications were resolved completely. No catheter needed to be removed and there were no leakages. The histological study of the cuff showed a good infiltration of the dacron cuff by fibrous tissue. On the grounds of our preliminary experience, we believe that the absence of the sinus tract, the formation of an efficient mechanical and bacterial barrier and the reduction of exit-site infection incidence are all factors that encourage further research.


Enhanced peritoneal dialysis delivery with PD-PLUS. We prospectively studied the effects of enhanced continuous ambulatory peritoneal dialysis (CAPD) on the normalized protein catabolic rate (NPCR) and Kprt/V of two patients with zero residual renal function and marginal or below minimal HCFA values on urea kinetic modeling (Kprt/V = 0.21). Predictable increases in NPCR (from 0.61 to 0.76 and from 0.73 to 0.81 gm/kg/day, respectively) were seen after two weeks of enhanced CAPD achieved by the addition of a fifth nighttime exchange by a portable, easily operable, automated device (PD-PLUS).


Analysis of clinical experience with a new twist lock connectology. The DextroLyte II (Dex II) Peritoneal Dialysis System was designed to improve safety and convenience in dialysis therapy. Connectors introduced with this system have a threaded recessed male connector with a corresponding female counterpart. Products are provided for CAPD, Single Use Y, Long Life Y and CCPD. Safety and convenience features intended to reduce peritonitis rates and improve patient acceptance include the following: 1. Connectors with threaded male and corresponding female counterparts which provide a dual seal 2. Easy-to-break frangible which seals the solution bag until ready for use 3. A flange on the connector ensures proper hand placement by providing a safety shield to prevent contamination during connection 4. A hinged shield containing an impregnated povidone-iodine sponge easily snaps around the bag connector 5. A Quick Disconnect Clamp (QDC) provides external occlusion permitting safe disconnection for bagless techniques without opening the system 6. A standard medication port provides easy access for administration of intraperitoneal medication Results of a multicenter study performed in nine centers are as follows: Total patient participants 121 Total patient months 1207 Overall peritonitis rate 1 episode in 43 patient months We conclude that the Dex II peritoneal dialysis systems provide safe dialysis therapy as evidenced by the exceptional peritonitis rates. Patient acceptance has been excellent due to the inclusion of the safety and convenience features described.


An assessment of the flow rate within peritoneal dialysis catheters, using a standardized in vitro technique. A variety of peritoneal dialysis catheters are used in clinical practice. The catheters are mainly described by their design, French number (circumference in mm) and length. However, this description does not provide information about the catheters inflow and outflow rates. We have therefore, studied flow rates of 18 adult catheters, using a uroflowmeter. Inflow rates were measured with the inflow bag 100 cm and 145 cm above the tip of the catheter, and outflow rates were measured with the flow transducer located 35 cm and 80 cm below the tip of the catheter, imitating situations where patients are sitting in a chair or laying in a bed during fluid exchanges. Ten measurements were made for each catheter at all heights. We found that catheter designs do affect flow rates. Straight catheters had statistic significantly faster inflow and outflow rates compared to curled catheters (p < 0.001). Moreover, curled catheters had statistic significantly faster flow rates than Swan Neck catheters (p < 0.001). The length and internal diameter of the catheter was found to be the determining factor for the differences in flow rates.


Subcutaneously implanted catheters reduce the incidence of peritonitis during CAPD by eliminating infection by periluminal route. Recent experiences with Y-connectors suggest that the flush-before-fill effectively reduces intraluminal infection. Periluminal infection, however, remains an important route of peritonitis (P). We have recently reported reduced P incidence with the introduction of a new access technique as described by Moncrief in which the external segment of peritoneal catheter is left implanted subcutaneously for 6 weeks before exteriorization and bag exchanges. P developed once every 14.0 patient-mos with the new access while the incidence was one episode per 10.7 mos with conventional access. Significantly fewer patients with the new access compared to those with conventional access experienced P during the observation period (p < 0.01). Although the overall incidence of exit-site infection (ESI) was not different, there were significantly fewer episodes of simultaneous P and ESI with the new access (2P in 47 episodes of ESI) than with conventional access (36P in 126 ESI). While 10 of the 36 episodes of simultaneous infection in the conventional technique were caused by same organisms, none of the 2 episodes with the new access technique was caused by same organisms. The results of this study suggest that the new access technique reduces P incidence by virtually eliminating infection by the periluminal route.


Choline levels in human peritoneal dialysate. The average free choline level was determined to be 14 M in peritoneal dialysates and 22 M in plasma of thirty patients on continuous ambulatory peritoneal dialysis (CAPD). Daily choline loss via dialysate averaged 129 moles with 32 moles choline lost per dwell. Daily choline loss via the dialysate was positively correlated with plasma choline concentrations. Choline levels in dialysate during CAPD exceed plasma levels of choline (9 M) in healthy individuals.


Treatment of relapsing peritonitis in pediatric patients on peritoneal dialysis. Relapsing peritonitis is often due to bacterial colonization of the Tenckhoff catheter and may require removal of the catheter in patients on peritoneal dialysis. The efficacy of a Tenckhoff catheter decontamination procedure was examined in 9 pediatric patients aged 1.5-18 years and compared to the outcome of a historical control group. After repeated dialysate cultures had become negative and cell count was normalized (< 100/ul), intraluminal urokinase (5000 IU/ml) and intraluminal high concentrated antibiotics (vancomycin, fosfomycin, cefotaxim) were instilled sequentially for 3 h and 1 h respectively. This procedure was performed once daily for three days. In addition, the connector was exchanged on the last day. This regimen prevented relapsing peritonitis in all study patients, whereas in the control group in 75.8% of events further relapses occurred, necessitating removal of the Tenckhoff catheter in 7/19 (36.8%) episodes. No side effects of intraluminal urokinase were recorded in any of the patients. We conclude that intraluminal urokinase and intraluminal high concentrated antibiotics combined with connector device exchange are highly effective for prevention of further relapses of peritonitis and reduce the need for Tenckhoff catheter exchange.


CAPD disconnect systems: UK peritonitis experience. We reviewed peritonitis (P) experience of four UK units using single use Y (Freeline T.M., Baxter UK)(F) and Twinbag (Solo T.M., Baxter UK) (S) disconnect systems, which incorporate the 'Flush Before Fill' principle. We aim to show clinical achievements, in varying circumstances, in the light of previously published in vitro study results. Each unit recorded P data, i.e., rates, causative organisms, and recurrences (R) over a 12 month period (Sept 89-Aug 90). This data was then analysed by system, by unit and in total. Each unit had similar definitions for P and R, but had varying system selection criteria. Unit 1 had a fairly open criteria for F use, then became more selective at the same time as introducing S. In unit 2, F, and then S, were first choice systems for all (inc. blind diabetics). Unit 3 trains every pt. on non-disconnect System 2, then pt. choice determines if they are retained onto a disconnect system. Unit 4 had a more highly selected population. Results, expressed as episodes/patient month, were as follows: [table: see text] We conclude that it is possible to achieve a low incidence of P, especially that caused by S. epidermidis, particularly with S. It would seem the extent is related to pt. to system selection criteria. The effects of R and ES/TI need to be addressed.


A randomized multicenter trial to evaluate the effects of UV-Flash system on peritonitis rates in CAPD. A number of systems and devices have been developed to reduce peritonitis in CAPD patients. One of the newer developed systems in the UV-Flash. A retrospective study was conducted in five Japanese hospitals to measure the efficiency of the UV-Flash system in reducing the peritonitis rate for CAPD patients. This study took place between January 1983 to January 1992. The UV-Flash system had a significantly lower peritonitis rate (1/46.6 patient months) compared to the Standard system (1/27.5), but showed nominal significance when compared to the Disconnect system (1/47.6). Due to the lack of differentiation in peritonitis rates between the UV-Flash and Disconnect system, patient types for both systems were analyzed. The study found more impaired patients on UV-Flash (37.2%) as opposed to the Disconnect (9.8%). These impaired patients treated on the UV-Flash system showed a significantly lower peritonitis rate (1/27.5) when compared to the Disconnect (1/9.7) system. The UV-Flash system proved able to achieve sufficient prevention of peritonitis in CAPD patients. Thus, this system can be successfully applied to high risk CAPD patients.


Swan neck presternal ("bath tub") catheter for peritoneal dialysis. We hypothesize that the swan neck catheter for peritoneal dialysis with exit in the presternal area will have better exit site healing and a decreased incidence of exit site infection than currently used peritoneal dialysis catheters with the exit located on the abdomen. The chest is a very stable structure, with minimal wall motion, especially of the upper chest and over the sternum. Hence, a catheter exit located on the chest will be subjected to only minimal movement. Decreased piston like movement of the catheter at the exit site reduces inward transfer of outer microbial flora. Moreover, a tight garment is usually not worn on the chest and there is less pressure on the exit. Based on this rationale a new catheter (swan neck presternal) has been designed. The presternal peritoneal dialysis catheter is composed of two flexible (silicon rubber) tubes joined through a titanium connector at the time of implantation. The device has been dubbed as a "bath tube" catheter because, with the exit on the chest, a patient may take a tub bath without the risk of exit contamination due to submersion. Two such catheters were implanted in two patients. One patient had multiple problems (including chronic exit site infection) with a previously implanted swan neck Missouri 2 catheter, the other patient was originally rejected as a peritoneal dialysis candidate due to extreme obesity. Both catheters healed well in 6 weeks and the exits have not become infected during the first 8 months. These preliminary experiences with 2 catheters support the rationale of their design.


Exit-site/tunnel infection and catheter outcome in peritoneal dialysis patients. To study exit-site/tunnel infections and catheter outcomes in peritoneal dialysis patients. The study was designed to investigate exit-site (ESI)/tunnel infections (TI) and catheter losses in all chronic PD catheters inserted in ESRD patients from 9/88 to 9/91. Tertiary-referral university hospital. Seventy-three patients (40 males, 33 females) underwent 78 double-cuff coiled swan-neck catheter implantations surgically. The curettage of exit site was performed weekly for tunnel infection refractory to medical management. The subcutaneous cuff was excised in persistent ESI/TI. Fifty-nine episodes of ESI/TI in 34 patients were observed over 946 patient-months. Thirty-nine patients experienced no ESI/TI, 27 patients had one and seven had two or more episodes of ESI/TI. Four patients had five episodes of peritonitis associated with ESI/TI. Eight recurrent episodes of ESI/TI with S. aureus in 8 patients were treated successfully with Rifampin. Seven subcutaneous cuffs were excised successfully in 7 patients with tunnel infection, five with S. aureus and two with Pseudomonas aeruginosa. No catheter was removed due to ESI/TI or ESI/TI associated peritonitis. Aggressive exit site care including repeated curettage, excision of the subcutaneous cuff and appropriate antibiotics reduced significantly catheter losses related to ESI/TI.


Effect of simvastatin in CAPD patients with hypercholesterolemia. The effect of simvastatin on serum total and HDL cholesterol and total triglyceride levels in 20 hypercholesterolemic patients on CAPD treatment was studied. The drug was given at the initial dose of 10 mg/day which was doubled up to 40 mg/day. Two non-compliant patients stopped the drug in the first week of treatment. One patient had vomiting and stopped simvastatin. One patients reduced the dose from 20 to 10 mg/day because of increase in CPK level. The study was completed in 16 patients. Serum cholesterol decreased from 318 +/- 39 to 208 +/- 34 mg/dl (p < 0.001), triglyceride from 317 +/- 129 to 278 +/- 160 mg/dl and HDL cholesterol from 43 +/- 13 to 35 +/- 11 mg/dl. The effective does was 10 mg/day in 4 cases, 20 mg/dl in 7 and 40 mg/dl in 5. In CAPD patients, simvastatin is safe and effective in lowering serum cholesterol. The clinical significance of the decrease in HDL cholesterol and its possible effect on clinical outcome are still unknown.


Is weight gain inevitable in most chronic peritoneal dialysis patients? In order to determine the long-term effects of continuous peritoneal dialysis on weight, 100 consecutive patients entering our program in 1988 were studied and followed for a maximum of 36 months. All patients underwent monthly evaluations including weight and biochemical surveys. Peritoneal equilibration tests were performed in 75 patients. A definite and significant trend was noted for weight gain during the first 17 months with a mean weight gain of 6.41 +/- 8.36 kg or 6.4% increase (p < 0.01). This was followed by a downward trend with a nadir on month 21 (p < 0.05). There were no significant differences in the change in weight for small or large patients. A positive correlation was noted between weight change and D/P creatinine at 12 and 24 months. Albumin concentrations remained stable throughout the period of observation. Serum albumin did not correlate with percent weight change nor with D/P creatinine. The frequency of peritonitis did not influence weight change in this population. The data suggest that there is marked interpatient variation, but the majority of patients on chronic peritoneal dialysis experience significant weight gain upon initiation of therapy. The trend is reversed after approximately 1.5 years of therapy raising the question of underdialysis due to loss of residual renal function or from patient selection after transfer of the healthier patients to transplantation and/or hemodialysis.


Growth hormone responses to pituitary and hypothalamic stimuli in CAPD patients treated with recombinant human erythropoietin. Several alterations of growth hormone (GH) secretion have been described in patients with chronic renal failure. The effect of chronic treatment with recombinant human erythropoietin (rHuEPO) on GH secretion in uremic patients undergoing continuous ambulatory peritoneal dialysis (CAPD) is not known. The purpose of this study was to assess the GH responses to both direct and hypothalamic stimuli in CAPD patients chronically treated with rHuEPO. Eight clinically stable and well-nourished patients (age 19-59 yr) treated with subcutaneous rHuEPO, 96.5 +/- 72.1 U/kg/week, during 6-25 months were tested with GH-releasing hormone (GHRH, 100 micrograms iv in bolus). Insulin-induced hypoglycemia (0.1 U/kg iv in bolus) and clonidine (0.15 mg/m2 po) were used as indirect stimuli for GH release. Baseline concentrations of insulin-like growth factor I (IGF I) concentration was also determined. Five CAPD patients matched for age and sex and not previously treated with EPO were studied as a control group. There was no statistically significant difference in baseline IGF I concentrations in EPO treated patients in comparison with control group (2.6 +/- 0.7 vs 0.9 +/- 0.3 U/ml). GHRH administration was followed by a GH release in the treated group that did not differ significantly from that obtained in controls (peak: 10.6 +/- 3.7 vs 15.2 +/- 7.8 micrograms l, area under the curve [AUC]: 16.3 +/- 5.6 vs 24.0 +/- 11.4 micrograms.h/l).(ABSTRACT TRUNCATED AT 250 WORDS)


Metabolic differences between persistent and routine peritonitis in CAPD. Changes in 10 metabolic parameters (body weight, blood hemoglobin, and serum albumin, urea, creatinine, cholesterol, triglycerides, potassium, calcium and phosphorus) were compared in 28 episodes of routine peritonitis and 27 episodes of persistent peritonitis. These infections occurred in 20 CAPD patients, all of whom acquired both types of peritonitis on separate occasions. Coagulase-negative staphylococci predominated in the routine infections, while Staphylococcus aureus and Gram-negative bacilli, especially Pseudomonas, were associated with persistent peritonitis. Decreases during infection were significantly larger in persistent as compared with routine peritonitis episodes for all 10 nutritional parameters. Time required for recovery of all nutritional variables except serum potassium and urea was significantly longer in the persistent episodes. Persistent peritonitis led to peritoneal catheter loss in 13 of the 27 episodes and was associated with 4 deaths, while routine peritonitis was associated with neither catheter loss nor death. In contrast to routine peritonitis, persistent CAPD peritonitis is associated with severe malnutrition, considerable morbidity, and mortality.


Bone mineral and aluminum concentrations in patients undergoing CAPD. CAPD results in continuous peritoneal transfer of hormones and minerals involved in the pathogenesis of renal osteodystrophy (RO). Moreover, although CAPD patients seem to have better control of serum phosphate concentration than hemodialysis patients, the need for aluminum-containing phosphate binders (ACPB) may still be present. In a prospective study meant to investigate the evolution of RO, we obtained 79 bone biopsies in 29 uremic patients (20 male, 9 female; age 25-59, mean 46). Of these, 22 were obtained at the beginning of treatment, 24 after 24 months, 23 after 36 months and 10 after 60 months. All patients were treated with CAPD (Viaflex, Baxter 2-2.5 L x 4-5 bags/day; Ca(++) + 3.5, Mg(++) 1.5 mEq/L) as the first modality of therapy and received oral calcitriol, aluminum hydroxyde and/or calcium carbonate and magnesium hydroxyde in order to maintain serum calcium (Ca) and phosphorus within the normal range. Qualitative bone histology, bone Ca and magnesium (Mg) (Flame atomic absorption spectroscopy) and aluminum (Al) concentration (Graphite furnace atomic absorption spectrometry) were determined. CAPD achieves a good control of RO as indicated by the tendency toward a decreased incidence of mixed osteodystrophy and predominant hyperparathyroid bone disease and improvement of osteoid lesions. A defective Ca content of bone is persistent in the observed period and positively correlated to bone Mg concentration. An increased level of Al was shown in the serum and bone. The highest bone Al content was found among patients with predominant osteoid bone disease. Also in CAPD, patients consuming ACPB are at risk of bone Al accumulation despite the low Al levels in the dialysate.


CAPD with low calcium dialysate and calcium carbonate: results of a 24-week study. Twelve patients (median age 44.5 years) on CAPD, who had previously used a dialysate calcium concentration of 1.75 mmol/l (for a median time of 11.5 months) were started on a low calcium dialysate (LCD) with a calcium concentration of 1.25 mmol/l and followed up for 24 weeks. During the first eight weeks, no changes in the doses of oral phosphate binders were made and serum ionized calcium decreased from 1.30 +/- 0.02 (mean +/- SE) mmol/l to 1.17 +/- 0.02 (p < 0.0001) and serum PTH (1-84) rose from 68 (median, range 16-397) ng/l to 147 (70-449, p = 0.005). After week 8, increasing doses of calcium carbonate were used to achieve target calcium levels of 1.20-1.30 mmol/l. No aluminum-containing binders were used. Calcium carbonate doses were increased from 2.3 (median, range 0.75-12) g/d to 6.8 (3.8-15.0, p = 0.0004) and serum phosphorus concentrations decreased from 2.00 mmol/l (median, range 1.25-2.67) at 8 weeks to 1.61 (1.18-2.39) at 24 weeks (p = 0.023). Serum intact PTH(1-84) values remained elevated despite the gradually increasing serum calcium concentrations. Hypercalcemia was recorded in 20/36 (56%) of blood samples during a period of four weeks before the start of LCD, and such episodes were observed in 15/89 (17%) of samples (p < 0.001) on LCD during the period when calcium carbonate doses were increased. It is concluded that on LCD 1) the number of episodes of hypercalcemia was markedly reduced, 2) higher calcium carbonate doses could be used, and thus 3) the control of serum phosphorus improved.(ABSTRACT TRUNCATED AT 250 WORDS)


Lovastatin in the treatment of hypercholesterolemia in CAPD. The authors studied the effect of lovastatin on five hypercholesterolemic CAPD patients with high risk of atherosclerotic cardiovascular disease. Patients took lovastatin 20 mg once daily for a mean period of 4.5 months. Pre- and post-treatment values of LDL and VLDL totals (325 mg/dl and 292 mg/dl, respectively) and of HDL (42 mg/dl and 43 mg/dl, respectively) had no significant statistical difference. Lack of significance may be due to low number of patients and short trial time. The study did demonstrate that lovastatin is well tolerated in CAPD patients.


Calcium, magnesium mass transfer and lactate balance study in CAPD patients with reduced calcium/magnesium and high lactate dialysis fluid. We studied calcium (Ca), magnesium (Mg) mass transfer (MT) in 10 and lactate balance in 5 CAPD patients using standard dialysis solution [(ST) (Ca 1.75 mmol/l; Mg 0.75 mmol/l; lactate 35 mmol/l)] and with reduced Ca/Mg, high lactate solution [(LC) (1.25 mmol/l; 0.25 mmol/l; 40 mmol/l respectively)]. Exchanges were performed with 1.36% and 3.86% glucose solutions. MT was calculated as mmol/exchange. Ca MT was +0.96 and +0.39 with ST 1.36% and 3.86% glucose respectively. Serum ionised Ca (iCa++) levels were less than fluid Ca during these exchanges. With LC 1.36% glucose it was -0.66 when ICa++ was more than dialysate Ca, but +0.66 when iCa++ was less than dialysate Ca. Ca MT was negative with LC 3.86% glucose irrespective of iCa++ levels. All patients were hypermagnesaemic (mean 1.24 mmol/l. Mg MT was +0.21 and -0.04 with ST 1.36% and 3.86% glucose respectively and -0.62 and -1.13 with LC 1.36% and 3.86% glucose respectively. The difference between mean lactate gain and bicarbonate loss was less (-0.4) during exchange with LC 1.36% glucose. Mean plasma TCo2 and plasma pH did not differ between ST and LC solutions. We conclude that reduced Ca/Mg, high lactate solutions should reduce hypercalcaemia/magnesaemia and maintain a better acid base balance in CAPD patients who may require Ca/Mg containing phosphate binders.


Beta 2 microglobulin in CAPD.

Beta 2 microglobulin in CAPD. The peritoneal clearance (Kp) and renal clearance (Kr) of beta 2 microglobulin (beta 2 m) were studied prospectively on 50 ESRD patients treated with CAPD, in order to determine the effect of the number of daily exchanges on Kp and to investigate the factors which influence the serum levels of beta 2m. Kr and Kp of beta 2m and creatinine (Cr) were calculated using standard formulae at the initiation of study and again at 6, 12, 18 and 24 months by collecting 24 hour urinary output and dialysate effluent. Kp of beta 2m of patients on 3 exchanges/day was .94 +/- .08 ml/min at the initiation of study and 1.1 +/- .08 at the end. For patients on 4 exchanges/day it was .99 +/- .14 ml/min and 1.1 +/- .12 respectively. There was no significant difference. Serum levels of beta 2m were lower on patients with significant residual renal function (RRF) (17 +/- .9 mg/L) than on patients without RRF (38 +/- 2 mg/L. p = .001). Serum levels of beta 2m correlated inversely with Kr of Cr and beta 2m at the initiation of study and at the end (r = .67 and .77 respectively, p = .0001). We conclude that serum levels of beta 2m correlate inversely with Kr of Cr and are expected to rise as RRF decreases. The combined peritoneal and renal excretion of beta 2m is less than its daily production. The number of dialysis exchanges does not influence Kp of beta 2m.


Evolution of lipid profiles in long-term peritoneal dialysis. Serial lipid profiles of 102 patients starting chronic ambulatory peritoneal dialysis (CAPD) in our renal unit from January 1985 to December 1990 were collected retrospectively. Transient triglyceride elevation was noted during the first two years of CAPD but declined to normal levels even lower than those at baseline by 60 months. Total cholesterol, HDL and LDL cholesterol levels did not change significantly. Lipid-lowering agents were begun in 17 patients before initiating CAPD, 5 of whom achieved lipid profiles warranting cessation of therapy. Five other patients started treatment while on CAPD. No statistical difference in patient mortality was found when patients hyperlipidemic at the initiation of CAPD were compared to their normolipemic counterparts. We conclude that the return to normal plasma triglyceride levels after transient triglyceride elevation during long-term CAPD implies that adaptative mechanisms of triglyceride production in response to chronic glucose overload may ensue.


Low turnover bone disease is the more common form of bone disease in CAPD patients. CAPD is considered a risk factor for low turnover bone disease. This was previously attributed to aluminum accumulation. We evaluated by biochemical and histomorphometric parameters (including double tetracycline labelling), 26 patients maintained on CAPD for 12-14 months. Three (11.5%) showed mild hyperparathyroidism, 5 (19.2%) osteitis fibrosa, 3 (11.5%) mixed forms, 4 (15%) osteomalacia and 11 (42.3%) adynamic bone disease. Only one patient with diabetes mellitus showed an aluminum stained bone surface > 10%. Intact PTH serum levels were lower in LTBD (133.2 +/- 128 vs 468.2 +/- 451 pg/ml; p < 0.05). We also evaluated prospectively 11 patients who underwent a bone biopsy at start of dialysis and after 12 months of CAPD treatment. Bone biopsies pre CAPD demonstrated normal-high bone turnover disease in 8/11 (72.7%) and low turnover bone disease in 3/11 (27%). In the follow-up biopsies, 2 patients showed osteitis fibrosa and other two mild forms. Low turnover bone disease was found in 7 patients (3 osteomalacia and 4 adynamic bone disease). We conclude that the predominant bone lesion in our CAPD patients is low turnover bone disease, predominantly adynamic forms, and aluminum does not seem to play a role on its genesis. Low intact PTH serum levels may be a predictor of low turnover bone disease.


Effect of lovastatin on hypercholesterolemia in chronic renal failure. Using a mouse model of chronic renal failure (CRF), the possibility of using lovastatin to treat hypercholesterolemia associated with CRF was examined. Renal failure was induced in 5 week-old, C57BL/6J mice by electrocoagulation of the right kidney surface followed by left nephrectomy 2 weeks later. Five weeks post-nephrectomy, BUN and serum total cholesterol levels were assessed and lovastatin treatment commenced. Upon sacrifice 4 weeks later, BUN, serum total cholesterol levels and hepatic HMG-CoA reductase activity were measured. Results showed that CRF induced significant increases in serum total cholesterol levels and enzyme activity. Treatment with lovastatin led to a dose-dependent reduction in serum total cholesterol levels without affecting the enzyme activity. These results suggest that the hyper-cholesterolemia in CRF is partly due to an increase in de novo cholesterol synthesis in the liver and that the lipid-lowering effect of lovastatin is mediated by an action other than the direct reduction of hepatic HMG-CoA reductase activity.


Low calcium (2.5 mEq/l) and high calcium (3.5 mEq/l) dialysate in peritoneal dialysis patients. To compare the effects of low-calcium and high-calcium dialysate in stable ESRD patients on peritoneal dialysis (PD). Dialysate containing 2.5 mEq/l and 3.5 mEq/l calcium in combination with oral calcium salts as phosphate binders were evaluated. Tertiary-referral university hospital. Fifteen patients (6 male, 9 female) on low-calcium (2.5 mEq/l) and 15 patients (6 male, 9 female) on high-calcium (3.5 mEq/l) dialysate were studied for 6 months. All patients received calcium acetate or calcium carbonate to control hyperphosphatemia before the study. Serum calcium, phosphorus and albumin did not differ before and after between the two groups. Three patients in low-calcium and five in high-calcium group developed hypercalcemia. Three in low-calcium group and four in high-calcium group required sucralfate to control hyperphosphatemia and hypercalcemia. Mean dose of elemental calcium was 1152 mg/day in low-calcium group and 790 mg/day in high-calcium group. A negative correlation (r = -0.82, p < 0.005) was observed between serum calcium and PTH at the end of study period in the low-calcium group. No such relationship was observed in the high-calcium group. Degree and frequency of hypercalcemia appeared similar with low-calcium and high-calcium dialysate in peritoneal dialysis patients.


Increased uptake of radio labelled white blood cells into abdomen of uremics on peritoneal dialysis. Peritonitis and exit-site tunnel infection are frequent causes of CAPD drop out. We studied 9 patients, 8 treated by CAPD and 1 by IPD. These patients underwent sonographic and scintigraphic study of the abdomen. All scintigraphic examinations showed a visceral uptake. In two cases, sub-clinical bowel inflammation, demonstrated by scintigraphic study, preceded a gram negative peritonitis. The scintigraphic study with radiolabelled white blood cells may be useful in identifying chronic aseptic inflammations and some bowel and exit-site conditions which are possible risk factors in some cases of peritonitis.


Gastrostomy buttons for feeding children on continuous cycling peritoneal dialysis. The promotion of growth in infants and young children with chronic renal failure (CRF) requires an aggressive approach to feeding, often in combination with early dialysis. Supplementary feeding has usually involved the use of nasogastric tubes, but these can have many problems. We report our experience with a gastrostomy button device (Bard Ltd.) for long term feeding. Ten children (7 male) had an initial gastrostomy catheter inserted at a median age of 2.0 years (range 0.25-8.5 years). None of the children required an operation for gastrooesophageal reflux and 6 had placement of the gastrostomy catheter at the time of insertion of the Tenckhoff catheter for continuous cycling peritoneal dialysis (CCPD). The catheter is usually exchanged for a similar sized (18 gauge) button device after 4 weeks. All ten children received CCPD in addition to overnight feeding using an enteral feeding pump. The buttons have been in use for a mean of 12 months (range 2-33 months) and are only changed if the anti-reflux valves fail. Nutritional goals have been achieved and growth parameters maintained or improved in 9 children. The button has many advantages over nasogastric tubes or gastrostomy catheters. It has been welcomed by our families in reducing the stress of feeding these young children.


Micronutrient supplementation in children on continuous cycling peritoneal dialysis (CCPD). Data on the micronutrient (vitamin and trace mineral) requirements of children on chronic peritoneal dialysis is limited. Few preparations are of suitable content and palatability. In a prospective study we have assessed and compared the serum levels and dietary intakes of micronutrients (vitamins A, E, B12, folate and zinc, copper, iron) in 7 children on CCPD who were receiving either Ketovite tablets (vitamins C, E and B complex) and Cholecalciferol or a more comprehensive supplement, Paediatric Renal Seravit (vitamins A, E, D, C and B complex with trace minerals). All children received nutritional supplements orally or via a gastrostomy button. These supplements contributed significantly to their nutritional intakes. The mean dietary intakes of the studied micronutrients, with the exception of vitamins A, E, B12 and folate, were below RDA (USA) values. The Renal Seravit was tolerated by only 5 of the 7 patients. There was no significant difference in serum levels of the micronutrients while on the Paediatric Renal Seravit compared to Ketovite. Serum iron levels remained low on both supplements. A comprehensive micronutrient supplement may still be required in children on prolonged dialysis.


Adequacy of solute and water removal in children treated with nightly intermittent peritoneal dialysis. Nightly intermittent peritoneal dialysis (NIPD) is an automated form of intermittent peritoneal dialysis which has potential medical and psychosocial advantages in comparison with CAPD/CCPD due to the lack of daytime exchanges. Data on solute/water removal in children on NIPD are nevertheless scarce, so that no clear indications for NIPD can yet be formulated in pediatric age. For this reason, 12 patients, mean age 10.49 +/- 5.81, mean body weight 23.73 +/- 10.92, with a residual creatinine clearance 1.70 +/- 2.30 ml/min/1.73 sqm, on NIPD for 14.7 +/- 5.4 months, underwent clearance studies over 3 days. Mean dialysis infusion volume was 460.08 +/- 196.30 ml/kg/day, with 10.33 +/- 1.22 h dialysis time. Peritoneal creatinine and urea clearances were 6.36 +/- 2.96 and 8.49 +/- 3.35 1/day/1.73 sqm, respectively. Combined creatinine and urea clearances averaged 6.12 +/- 2.21 and 6.96 +/- 2.16 ml/min/1.73 sqm, resulting in serum creatinine and urea values of 7.78 +/- 1.90 and 115.58 +/- 29.93 mg/dl, respectively. Ultrafiltration rate was 16.94 +/- 16.34 ml/g glucose absorbed. NIPD provided similar or improved solute and water clearances compared with those reported in children and adults on CAPD/CCPD, without inconvenient long periods in bed. These data indicate that NIPD is a suitable treatment in pediatric end-stage renal disease.


Continuous peritoneal dialysis in children. During the period from June 1985 to December 1991, 48 children were treated with continuous peritoneal dialysis (CPD) in our centre because of acute renal failure. The median age was 1.8 years (range 0.01-17.1). The most common diagnoses were: hemolytic uremic syndrome (n = 22), anuria after cardiac surgery (n = 7), and septicemia with multiorgan failure (n = 7). Kidney function recovered in 35 (73%); 13 (27%) died of their original disease. One further patient with HUS recovered from dialysis but died of cerebral complications shortly afterwards. One patient remained anuric and requires renal replacement therapy. Hyperkalemia, when present initially, and uremia could be controlled adequately in all cases. However, ultrafiltration posed problems when cardiac output was low. Peritonitis occurred in 11 patients; in 8 children the Tenckhoff catheter had to be revised because of leakage (5), flow problems (2), or bowel perforation (1). CPD proved to be an excellent method to treat acute renal failure in children of all age groups. The rate of complications was acceptable.


Evaluation of peritoneal solute transfer by the peritoneal equilibration test in children. To evaluate the characteristics of peritoneal kinetics in the young, we investigated solute and water transfer rates by a modified Peritoneal Equilibration Test (PET) in 20 pediatric patients aged 1.9 to 19.8 years. 1000 ml/m2 body surface area of a 2.3% glucose PD solution were instilled in the peritoneal cavity. Glucose, creatinine, urea, sodium, potassium and phosphate were measured in the dialysate (D), 7 times during 4 hours and in plasma (P) after 2 hours dwell time. At 4 hours, the mean (+/- SD) D/P ratio was 1.06 +/- 0.16 for urea, 0.79 +/- 0.14 for creatinine, 0.82 +/- 0.21 for potassium, 0.92 +/- 0.04 for sodium and 0.79 +/- 0.30 for phosphate. Mean D/D0 of glucose was 0.36 +/- 0.13. The 4-hour solute equilibration curves were analytically best approximated by logarithmic functions for urea (mean R2 = 0.983), creatinine (R2 = 0.973) and potassium (R2 = 0.979), by a linear function for phosphate (R2 = 0.964), and by an exponential model for glucose (R2 = 0.969). The linear or exponential regression coefficients were used to express the peritoneal solute transfer rates. Although the transfer rates of most solutes were correlated with each other, the individual variation of peritoneal permeability for different solutes was high. Close associations were observed between the glucose and creatinine transfer rates (r = 0.91, p < 0.0001) and between ultrafiltration rate and glucose (r = -0.90, p < 0.0005) and creatinine (r = -0.88, p < 0.005). Peritoneal permeability for all solutes tended to be inversely correlated with body size (urea transfer rate vs. height: r = 0.49, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)


Five years' experience of the Italian Registry of Pediatric Chronic Peritoneal Dialysis. The results of the first 5 years' experience of the Italian Registry of Pediatric Chronic Peritoneal Dialysis (CPD) (1986-1990) are presented. Patients of less than 15 years of age at start of dialysis were enrolled and clinical data collected until the age of 19. The number of the dialysis centres participating in the Registry increased from 7 in 1986 to 15 in 1990. The total number of patients on CPD was 119, the number of new patients per year ranged from 15 to 28 and the percentage of all dialysed children treated with CPD increased from 40% in 1986 to 49% in 1990. The age of patients at start of CPD was 8.5 +/- 4.9 years and 16% of them were under 2 years. Only CAPD was utilized in 1986, while CCPD/NPD accounted for 53% and 65% of the treated patients in 1989 and 1990, respectively. At 4 years, patient survival was 91.3% and technique survival 79.3%. A comparison between data of 48 patients on CPD and 34 on hemodialysis, who started dialysis in the period 1989-1990, showed that CPD was the most frequent form of initial therapy (56%) and was the treatment of choice for children younger than 4 years.


Peritonitis in children undergoing chronic peritoneal dialysis (CPD): data from the Italian Registry of Pediatric CPD. During the period 1986-1990, 119 patients were enrolled in the Italian Registry of Pediatric CPD. CAPD was largely predominant in the first 3 years, while CCPD accounted for 48% of dialysis months in the period 1989-1990. The connect-disconnect system was a Y set for all patients during the whole observation period. The incidence of peritonitis decreased from 1 episode: 10.9 patient-months in 1986 to 1:19.8 in 1988, and then passed to 1:16.2 in 1990. A comparison of the incidence of peritonitis between CAPD and CCPD, referring to the 1989-1990 period, showed no significant difference. The percentage of positive peritoneal fluid cultures changed from 48% in 1986 to 73% in 1990. Gram-positive bacteria, primarily Staphylococcus aureus and Staphylococcus epidermidis, accounted for most of the isolated organisms. Candida albicans was cultured in 3 cases both in 1986 and 1987. Exit site infection was the predominant (82%) complication, followed by leakage and catheter cuff extrusion. The hospitalization rate for peritonitis resulted persistently high (61% of episodes) and the mean duration was 12.7 days. Of the 8 patients who were switched to hemodialysis, 4 had recurrent peritonitis and 1 Candida albicans peritonitis.


Bicarbonate is not the ultimate answer to the biocompatibility problems of CAPD solutions: a cytotoxicity test of CAPD solutions and effluents. Human polymorphonuclear granulocytes (PMN) were tested for migration and phagocytosis after exposure to CAPD solutions and effluents sampled during the first hour of dialysis from patients treated with lactate or bicarbonate based CAPD-solutions. The effluents from the lactate based solutions (Dianeal and Lockolys) reduced the migration and enhanced the phagocytosis compared to values obtained in a standard cell culture medium. Both cell functions increased during the dialysis period. In contrast, the cell-function only changed slightly when 87b, a bicarbonate based CAPD-solution (pH = 7.4, [HCO3-) = 29mM), was employed. During the first 30 minutes, the cells performed at a higher level when exposed to the 87b effluent than when exposed to the lactate effluents. The observations further indicated that optimal conditions for PMNs are at a bicarbonate concentration of less than 20 mM and a lactate concentration of less than 15mM. PMN migration is reduced by both lactate and bicarbonate based CAPD solutions and effluents collected during the first hour of dialysis. The bio-compatibility of CAPD solutions may be improved by combining the lactate and bicarbonate buffering systems in a solution with a concentration of less than 20 mM of bicarbonate and less than 15 mM of lactate.


Benefits of a mainstreamed summer camp experience for teens with ESRD. This is a report on a pilot project integrating children with end stage renal disease (ESRD) with well children for a summer camp experience. As the teen with ESRD prepares to enter the work force and college, he/she will have to adapt to a variety of situations that will not adapt to his/her unique medical condition. These issues motivated a pilot project in which 9 ESRD children were mainstreamed into a 2 week, YMCA summer camp experience. Pre and post questionnaires were developed and distributed to the camper, family, and the cabin counselor along with interviews to assess the value of the experience. All the children left camp more independent and knowledgeable about their self-care. The results of this pilot project indicate that children with ESRD can adapt to their environment and increase independence, self-care and self-esteem through supervised mainstreamed experiences.


Successful management of CAPD in infants with cardiac failure. Continuous ambulatory peritoneal dialysis (CAPD) was selected and introduced as a primary dialysis method in two infants with cardiac failure. CAPD was started at 14 days after birth with body weight of 2125 gm and at 7 months of age with body weight of 2325 gm. In both cases, cardiac failure was due to large ventricular septal defect (VSD) and renal failure was due to dysplastic kidneys. In the first case (case 1), direct closure of atrial septal defect and patch closure of VSD were successfully completed at 9.5 months of age with body weight of 4844 gm. CAPD has been managed well for 1 year and 8 months and the child reached a body weight of 8440 gm. In the second case (case 2), CAPD was managed well for 11 months with body weight increasing to 4920 gm at the age of 1 year and 7 months. This marked deterioration of this boy's physical growth was mainly caused by the delay in introducing CAPD and partly due to his cardiac dysfunction which has not been corrected surgically. Both cases show almost normal mental development and are managed well at home. Although CAPD introduction yielded water balance and physical growth in these infants, earlier introduction of CAPD may result in better clinical outcomes including management following open heart surgery. Selection of CAPD as a primary dialysis maneuver is strongly recommended for uremic infants with cardiac failure.


Acute peritoneal dialysis utilizing a non-luminal channeled catheter in infants. Acute peritoneal dialysis in unstable infants is at times plagued by early catheter malfunction secondary to omental plugging in both rigid acute catheters and conventional Tenckhoff catheters. This problem is inherent to the design of catheters using sideports for outflow and is enhanced by the tenacity of the omentum in this population in walling off foreign bodies. We have modified and utilized a non-luminal, channeled surgical drain for acute peritoneal dialysis in infants to avoid this problem. Five infants ranging in age from 2 days to 7 months were dialyzed acutely in a Pediatric Intensive Care Unit setting for periods ranging from 5 to 34 days utilizing this modified catheter. The infants ranged in weights from 1.96 to 8 Kg. Catheters were placed by a surgeon and peritoneal dialysis was initiated using a Y-setup. In none of the patients was there loss of catheter function secondary to omental plugging. Three patients subsequently died of their underlying illness and two recovered renal function. Two acute catheters were subsequently changed to conventional Tenckhoff catheters when it became apparent that dialysis would need to be performed for a prolonged time. The acute catheter which was used has a four channel cloverleaf appearance when cut in cross section with no central lumen. There is a transition to a luminal catheter outside the peritoneal cavity. The advantage of the cloverleaf configuration is the ability to exchange fluid along its entire intraperitoneal length, thereby excluding a defined area of catheter sideports where omentum can occlude the system causing a ball valve phenomenon.(ABSTRACT TRUNCATED AT 250 WORDS)


Could CAPD modulate the hemodynamic changes induced by rHuEPO treatment? Hemodynamic response to treatment with erythropoietin has been analyzed on two different groups of patients. The first group of 25 patients was treated with hemodialysis. The second group of 27 was treated with peritoneal dialysis. Both groups were studied before starting the treatment with erythropoietin, after reaching the hemoglobin target point, and after one year of treatment. The following parameters were recorded: basal and hemoglobin target point, time and dosage of response, incidence of arterial hypertension, diastolic and systolic left ventricular diameters, interventricular septum and posterior wall thickness, ejection fraction, fractional fiber shortening, left ventricular mass index, cardiac output index and peripheral resistance index. The incidence of hypertension was 28.8% and, in both techniques, stabilization of left ventricular mass index occurred a year later. When the hemoglobin target point was reached, a decrease in cardiac output and an increase in peripheral resistance was found. These changes were more evident in the group of patients treated with HD. After a year of treatment, both peripheral resistance and cardiac output were similar to basal values in both groups of patients.


Once weekly subcutaneous administration of recombinant erythropoietin in children treated with CAPD. Treatment with rHuEpo can eliminate many symptoms that had been attributed to uremia. Repetitive punctures in children undergoing three times weekly subcutaneous (SC) rHuEpo can result in noncompliance with the therapeutic regimen. The aim of this study was to evaluate the efficacy of once weekly SC injection of rHuEpo in children with end-stage renal disease (ESRD) on CAPD. Six children (5 males, 1 female, mean-age: 6.0 years, range: 0.5 to 15.8 years) with ESRD on CAPD were treated with a regimen of rHuEpo 150 U/Kg/week SC for 12 weeks. All patients received oral iron supplementation. All children had improved appetite and well-being. The adolescents showed an increased ability to engage in regular activities. The hematocrit increased from 20.3 +/- 1.2% to 31.7 +/- 3.8% in 12 weeks. The mean weekly increase in hematocrit was 0.95 +/- 0.34%. There was no significant differences in iron indice prior to and during rHuEPO treatment. Side effects related to rHuEpo included transient pain at the site of injection in all, pruritus at the site of injection in 1 child, hyperphosphatemia in 1 infant, iron relative deficiency in 2 children and an asymptomatic increase in blood pressure in 1 hypertensive child. None of the 5 normotensive patients developed hypertension. We concluded that once weekly 150U/kg SC rHuEpo is effective in correcting anemia in children on CAPD. This regimen results in few side effects, decreases the cost of treatment and produces less distress to the patients by avoiding repetitive injections.


A prospective open-label study evaluating the efficacy and adverse reactions of the use of Niferex-150 in ESRD patients receiving EPOGEN. Iron supplementation is usually required in patients receiving epoetin alfa. Ferrous sulfate is commonly prescribed, however many patients experience adverse gastrointestinal effects. Adverse effects may limit the amount of iron that can be prescribed, and may lead to noncompliance. Polysaccharide-iron complex (PIC) is an iron supplement containing greater amounts of elemental iron, and may produce fewer adverse effects. This study compared the efficacy and adverse effects of PIC to a historical period of treatment with ferrous iron salts to 38 dialysis patients receiving epoetin alfa. All patients were switched to PIC, and were followed for six months. The following laboratory information was recorded: hematocrit, serum iron concentration, percent transferrin saturation, total iron-binding capacity, serum ferritin concentration. Patients were given an adverse experience questionnaire at four and six months of PIC treatment. No differences in laboratory values were noted between treatments. The amount of prescribed elemental iron increased, while iron dextran use decreased during PIC therapy. Epoetin alfa doses were unchanged. Patients reported fewer gastrointestinal adverse effects at four months, however differences at six months were less striking. PIC is as effective as ferrous sulfate in sustaining erythropoiesis in patients receiving epoetin alfa. It may produce fewer adverse effects.


Erythropoietin associated hypertension among pediatric dialysis patients. The major side effect of rHuEPO is hypertension, which is reported to occur in 10-75% of adult patients. The aim of the present study is to evaluate the effect of rHuEPO on blood pressure in pediatric dialysis patients. Nine CAPD patients (mean age 7.4 +/- 3.6 years) and fourteen HD patients (mean age 13.8 +/- 5.5 years) were treated with rHuEPO. The hematocrits increased significantly from 20.7 +/- 1.8 to 28.3 +/- 4.1 in HD patients and from 19.7 +/- 2.9 to 26.7 +/- 4.4 in CAPD patients. The final maintenance dose required to correct the anemia was 47.6 +/- 11.7 units/kg/week for CAPD patients and 122.6 +/- 75.2 U/kg/week foe HD patients. Six (66.6%) out of nine CAPD patients, and five (35.7%) of fourteen HD patients developed or worsened hypertension. Younger CAPD patients tended to develop hypertension. Correction of anemia was poor in two hypertension-exacerbated patients, since rHuEPO dose increase was withheld for fear of aggravating hypertension. A four-year-old girl developed hypertensive encephalopathy after 13 months of rHuEPO therapy. No difference was observed in plasma level of aldosterone or plasma renin activity. Hypertension is observed frequently among pediatric dialysis patients treated with rHuEPO therapy. Careful monitoring and management of hypertension is required, especially in the first three months of rHuEPO therapy.


Effects of erythropoietin-induced hemopoiesis on peritoneal transport and on in vitro T cell response in CAPD. In order to investigate the therapeutic efficacy of subcutaneously administered erythropoietin (rHuEPO) and the effects of rHuEPO-induced hemopoiesis on peritoneal transport and on cellular immune responses, we performed standardized peritoneal equilibration tests and measured T cell subsets and phytohemagglutinin (PHA)-induced interleukin-2 receptor (IL-2R) expression of PBMC by flow cytometry before and after subcutaneous rHuEPO (Eprex-, Cilag), 4000 U twice weekly, in 13 stable CAPD patients. Hct increased from 21.3 +/- 3.4% to 30.0 +/- 4.8% after 1 mo and to 32.7 +/- 4.9% after 2 mon of rHuEPO. Drained volume after 4 hrs of dwell with 4.25% dialysate increased from 2,675 +/- 204 ml to 2,807 +/- 174 ml (P < 0.05). D4/P4 creatinine increased from 0.68 +/- 0.07 to 0.71 +/- 0.06 (P < 0.05) and creatinine clearance from 7.57 +/- 0.71 to 8.03 +/- 0.63 ml/min (P < 0.05). The number of total circulating lymphocytes, T4,T8, T4/T8 with or without PHA did not change after rHuEPO. PHA-induced IL-2R expression by PBMC as expressed by mean channel of fluorescence intensity increased from 149.8 +/- 6.7 to 156.8 +/- 6.1 (P < 0.05). Subcutaneous rHuEPO is effective in correcting anemia in CAPD patients. rHuEPO-induced hemopoiesis is associated with increase in peritoneal creatinine and water transport and also with PHA-induced IL-2R expression.


How does rHuEPO effect D/P creatinine ratios? Initially starting CAPD patients on EPO was concerning after hearing reports of hemodialysis patients stating that they "may need more dialysis". The rationale given was that with a higher hematocrit the percentage of plasma in whole blood would decrease, leading to an increase of red cell mass. This decreased plasma volume and increased viscosity would lead to a slower blood flow ultimately resulting in less efficient dialysis. Assessing CAPD patients' peritoneal efficiency was the next step. We obtained pre and post-EPO PETs and evaluated. The initial results showed that D/P creatinine ratios were dropping as our Hcts increased, and ultrafiltration results projected an improvement. What remained unanswered was what took place over extended periods of time on EPO therapy. We examined twelve patients over a period of 27 months. Each patient received 4 exchanges per day using 1500 to 2500 volume. PET tests were performed on each patient prestudy, and at months three, six, and 25-27. Initially each patient received EPO 4000 units, 3/week, SQ. EPO easily increased and maintained our patients' hematocrits within 12 weeks after starting the study. D/P creatinine ratios initially dropped but as our study continued there was a return of D/P creatinine ratios to 6% greater than baseline. One report suggests that EPO may have a direct vasoconstricting effects on blood vessels caused by the stimulation of calcium toward the cell. Vasoconstriction of the vessels would lead to a decrease in exchangeable surface area resulting in a decreased D/P creatinine ratio.(ABSTRACT TRUNCATED AT 250 WORDS)


Effect of the correction of anemia with recombinant human erythropoietin on growth of children treated with CAPD. Anemia correction with recombinant human erythropoietin (EPO) has been suggested to have a positive effect on nutritional status by improving appetite and protein metabolism. To assess this effect growth velocity and various parameters of nutritional status of 10 children on continuous ambulatory peritoneal dialysis (CAPD) were estimated at the start and one year after the correction of anemia. There was no significant improvement of growth velocity after EPO administration. Energy and protein intake, standard deviation scores of anthropometric measurements, BUN, serum creatinine, albumin, potassium, phosphorous and protein catabolic rate did not differ significantly before and after EPO administration. There was a significant correlation of protein intake and protein catabolic rate. There was no significant improvement of nutritional status and growth of children on CAPD treated with EPO, possibly because there was no evidence of malnutrition in most patients.


Iron dextran treatment in peritoneal dialysis patients on erythropoietin. To evaluate maintenance parenteral iron dextran in chronic peritoneal dialysis (PD) patients receiving erythropoietin (rHuEPO). Parenteral iron dextran was investigated in PD patients with poor response to rHuEPO and/or side effects of oral iron. Tertiary-referral university hospital Seven ESRD patients (five males and two females) were studied. A test dose of 25 mg iron dextran was given before starting a maintenance dose. Iron dextran 100 mg was given intramuscular weekly or biweekly. Six patients received rHuEPO and one patient was on decadurabolin. Hematocrits increased significantly (p < 0.01) from 29 +/- 2% to 38 +/- 2% and serum ferritin increased from 267 +/- 104 to 660 +/- 104 ng/dl after iron dextran. Serum albumin increased from 3.1 +/- 0.3 to 3.6 +/- 0.2 g/dl (p < 0.05). No patient developed an anaphylactic reaction or delayed reaction. Mean duration of parenteral iron dextran treatment was 7 +/- 1 months. Mean dose of erythropoietin was reduced significantly (p < 0.05) from 119 +/- 20 units/kg/week to 87 +/- 20 units/kg/week before and during fifth month of iron dextran therapy. Weekly/biweekly maintenance intramuscular iron dextran injection was effective and safe iron supplemental therapy in PD patients with poor response or side effects to oral iron.


Peritoneal dialysis efficiency in CAPD patients in treatment with rHuEPO. Possible modifications in peritoneal behaviour that can be caused by erythropoietin (EPO) treatment and/or correction of anemia in the ultrafiltration and peritoneal diffusion were studied in 24 CAPD patients. The evolution of the patients on the medium run was also studied. The dialysate to plasma ratio, the peritoneal clearance and the mass transfer coefficient of urea and creatinine and the ultrafiltration volume were studied, baseline, after reaching the hemoglobin target, and after eight months of treatment. The group of patients developed a decrease in the dialysate to plasma ratio and in the peritoneal clearance of creatinine. After evaluating the effects of the hemoglobin and the hematocrit, we found a decrease in the dialysate to plasma ratio of urea and creatinine, and in the peritoneal clearance of creatinine. A decrease was also found in the mass transfer coefficients of urea and creatinine. An increase in the ultrafiltration was also found in the patients with hemoglobin levels higher or equal to 11 g/dl. Those changes are reversible after turning the hemoglobin levels back to levels lower than 11 g/dl.


Effect of CAPD dialysate on the release of eicosanoids and cytokines from human peritoneal macrophages. The effect of fresh peritoneal dialysis (PD) solution and effluent on the generation of eicosanoids and cytokines by human peritoneal macrophages (PMO) was studied in vitro. PMO, isolated by density gradient separation from patients undergoing intermittent peritoneal dialysis (IPD), were incubated for 2 h with PD effluent after dwell periods of 5 to 240 min or fresh PD solution. Supplemented RPMI-1640 medium served as control. PMO were stimulated by calcium ionophore A23187 (10 M). PD solution significantly inhibited the release of prostanoids (PGE2, TXB2, 6-k-PGF1), leukotrienes (LTB4, LTC4), and cytokines (11-6, TNF) from PMO by 60 to 96% (p < 0.05). Addition of A23187 increased the generation of TXB2, LTB4, and LTC4 in PD solution adjusted to pH 7.4 to 2.7 up to 28.6 times the basal level, but was ineffective in PD fluid at pH 5.2. Incubation of PMO with PD effluent of varying dwell times resulted in a rise of all assayed mediators (p < 0.05). The release of IL-6 increased continuously from 80 +/- 10 pg/10(6) PMO (0 min dwell time) to 440 +/- 104 pg/10(6) PMO (4 h dwell time, mean +/- S.E.M.). TNF generation rose from 6.0 +/- 0.1 pg/10(6) PMO (0 min dwell time) to 162 +/- 54 pg/10(6) PMO after 5 min dwell time and remained constant with effluents of longer dwell times (15 to 240 min). Exposure of PMO to PD effluents after 240 min dwell time tended to decrease the median levels of PGE2, TXB2, and 6-k-PGF1.(ABSTRACT TRUNCATED AT 250 WORDS)


Urea kinetics evaluation of hemodialysis and CAPD patients. Urea kinetics have been used to measure adequacy of hemodialysis. The role of urea kinetics in CAPD has not been clearly established. Using urea kinetics, we studied 71 hemodialysis and 71 CAPD patients. Age was 53 +/- 12 and 45.8 +/- 12 respectively. Urea kinetics in hemodialysis were studied in the standard manner. CAPD patients collected 24 hr, dialysate fluid to measure urea, creatinine, glucose and protein. Urine was collected for 24 hr. to measure urea and creatinine. Protein catabolic rate (pcr) was calculated from the total amount of urea cleared in 24 h. Both groups of patients had similar body weight. Kt/V in CAPD (0.65 +/- 0.1) was at a level considered underdialysis for hemodialysis. In both groups, pcr increased as Kt/V increased. However, CAPD patients had levels of pcr higher than hemodialysis patients at the same level of Kt/V. BUN, serum albumin and serum potassium were significantly lower in CAPD patients. Patients who dialyze more, eat more. Differences in protein intake may be due to a more liberal diet in CAPD, patient selection, removal of middle molecules, or better control of the acidosis.


Clinical experience and comparative analysis of the standard and fast peritoneal equilibration tests (PET). The fast peritoneal equilibration test (PET) has been proposed as a substitute procedure for the standard PET because it is less expensive and less time consuming since fewer samples must be drawn. This study was undertaken to compare the fast and standard PETs to determine if the fast PET is a viable alternative. Fifteen patients participated in the study. Results from the standard PETs indicate 13 patients had average permeability and 2 patients had high transport. Corresponding fast PETs indicate 10 patients with average permeability, 2 patients with high transport, 1 patient had discrepancies between the D/P ratios and drain volume, and 2 patients were noncompliant and did not complete the fast PET. We conclude that the fast PET is a valid screening tool to evaluate peritoneal membrane permeability in patients who have previously undergone a standard PET. It is cost effective and timesaving. The test is easily invalidated if patients fail to comply with instructions for the test. The fast PET is primarily useful as a screening device to determine whether permeability has changed.


Marked improvement in parameters of renal osteodystrophy with the use of intraperitoneal calcitriol. Parenteral administration of Calcitriol is felt to be superior to oral Calcitriol in the treatment of renal osteodystrophy in chronic renal failure patients. We analyzed the results of serum calcium, phosphorus, alkaline phosphatase, and N-terminal parathormone level which are the clinical parameters of renal osteodystrophy in twenty-three chronic peritoneal dialysis patients who received varying dosages of intraperitoneal Calcitriol. The results which were analyzed at the end of one to twenty-three months revealed significant increase in serum calcium and a significant decrease in the values of alkaline phosphatase and N-terminal parathormone level.


Urea kinetics has limited relevance in assessing adequacy of dialysis in CAPD. The application of urea kinetics to CAPD is controversial. Additional data is presented from our recent study on this topic. Different methods of calculating KT/V and normalized protein catabolic rate (PCRN) are compared and KT/V is shown to be on average 6.5% higher when V is calculated by Watson's formulae instead of by body weight alone. This discrepancy increases with time. It is also shown that standard methods may overestimate KT and underestimate PCRN. KT/V and PCRN by these different methods do not correlate with clinical outcomes. However, if V is calculated by Watson's formulae, there is a significant excess of deaths when KT/V is under 0.5 (weekly KT/V under 1.5). Survival curves show that neither initial KT/V nor PCRN predict failure on CAPD.


Interactions of cells from peritoneal dialysate with mesothelial cells and fibroblasts in culture. Peritoneal mesothelial cells and fibroblasts were co-cultured in vitro with peritoneal white blood cells (PWBC) obtained from CAPD patients, after an overnight exchange with 0.5% Dianeal or 2.5% Dianeal. Unstimulated PWBC inhibited proliferation of mesothelial cells and fibroblasts. Upon stimulation with lipoposaccharides (LPS), PWBC from the 0.5% dextrose exchange, enhanced the growth of mesothelial cells and fibroblasts, whereas when stimulated with LPS, PBWC from the 2.5% dextrose exchange increased only proliferation of fibroblasts.


Hospitalization: CAPD versus hemodialysis and transplant. We studied morbidity in 648 patients treated in our center in a ten-year period as indicated by duration of hospitalization: 232 patients were on CAPD, 188 on hemodialysis (HD) and 228 had cadaveric kidney transplants (Tx). Duration of hospitalization was divided into four groups according to its causes. The age of the patients on CAPD was 61 +/- 14 years, 53 +/- 17 on HD and 36 +/- 10 in the Tx group. The total follow-up was 629 patient-year (p-y) on CAPD, 458 p-y on HD and 928 p-y on Tx. The first admission was longer on CAPD (30 +/- 18 days) and on Tx (36 +/- 18 days) than on HD (18 +/- 12). After the first admission, the total days of hospitalization (days/patient-year, d/p-y) were more for CAPD than HD and Tx. Analysis of these data showed that the difference was due to peritonitis and to the different percentage of elderly patients in the CAPD group. With a reduction in the incidence of infectious complications (peritonitis, tunnel or exit-site), hospitalization in CAPD could be reduced to a length of time similar to that currently needed by HD and Tx patients. This can result in important cost-saving.


Pulmonary function variation in ventilator dependent critically ill infants on peritoneal dialysis. Four ventilator dependent infants on PD for acute renal failure underwent pulmonary function (PFT) evaluation at varying times in the PD cycle. Mid dwell peak intraperitoneal pressure (IPP) correlated with a significant decrease in pulmonary compliance and increase in air way resistance. This further correlated with a decrease in PO2 and an increase in PCO2 on arterial blood gas analysis. Etiology of the PFT changes appear to correlate most closely with IPP yet other factors including pulmonary artery shunting as well as hypercapnea secondary to a 4.25% dialysate are being evaluated as additional causative factors.


A review of urea and creatinine kinetics in predicting CAPD outcome. The adequacy of the peritoneal dialysis prescription is of great concern. Although the use of urea kinetics has become the standard in hemodialysis, its usefulness in peritoneal dialysis is unclear. It has been suggested that creatinine clearance may correlate with clinical outcome in CAPD but, as with urea kinetics, its predictive value is not established. The efficacy number (EN), which only requires a four hour exchange, was introduced as a simpler approach to creatinine kinetics. These three kinetic models were correlated to clinical outcome in 18 stable CAPD patients over a 12 month study period. The patients were divided into three groups: good (G), intermediate (I), and poor (P) based on uremic symptoms, mortality, hospital days, biochemical indices and the need for transfer to hemodialysis. Both forms of creatinine kinetics (weekly creatinine clearance, EN) were able to differentiate between the G, I, and P outcome groups (P < 0.05). The weekly uea Kt/V was able to differentiate between the G and P groups (P < 0.05) but not between the I and the other two outcome groups. Both urea and creatinine kinetics predict clinical outcome in CAPD. However, creatinine kinetics may be a more sensitive predictor. The efficacy number was just as sensitive as creatinine clearance in predicting clinical outcome yet simpler to gather the data for its calculation.


Nutritional status in long-term CAPD patients. We studied normalized urea nitrogen appearance (NUNA), normalized protein catabolic rate (NPCR), and normalized daily creatinine excretion (NDCE) in twenty-one patients (15 men, 6 women; mean age 63 +/- 9 years) on CAPD for more than 4 years (80 +/- 27 months). In the same patients we evaluated the changes in serum albumin and transferrin with time. After 74 +/- 26 months on CAPD, NUNA was 0.12 +/- 0.03 g/Kg IBW/day, NPCR = 1.09 +/- 0.19 g/Kg IBW/day; NDCE = 15.1 +/- 3.1 mg/Kg IBW/day; serum albumin = 3.8 +/- 0.2 g/dl. NUNA was correlated with NPCR (p < 0.001) and both were correlated with NDCE (p = 0.007 and p = 0.008). NPCR significantly decreased as patient age increased (p = 0.007) but was not correlated with time on CAPD, sex or serum albumin. Serum albumin did not change as age increased. Serum albumin and serum transferrin had not significantly changed after 4 years (after 8 years in a subgroup of eight patients). Finally, we compared these data to the initial data recorded for the same patients (mean interval: 64 +/- 21 months). NUNA, NPCR and NDCE did not change significantly. Changes in NPCR were directly related to changes in NDCE (p = 0.019). This study supports that long-term CAPD does not necessarily impair nutritional status and suggests that the oldest patients can maintain stable serum albumin concentrations on lower protein intake than younger ones.


Canada-USA (CANUSA) multicentre study of peritoneal dialysis adequacy: description of the study population and preliminary results. CANUSA Peritoneal Dialysis Study Group. The adequacy of peritoneal dialysis should be defined by clinical outcomes. Studies using multivariate techniques to evaluate the effect of demographic and clinical risk factors on these clinical outcomes showed worse patient survival for age > 60 years, diabetes mellitus, history of cardiovascular disease, black race and prior ESRD therapy. The single study reporting a multivariate analysis of urea kinetics and these baseline prognostic factors on clinical outcome showed serum albumin to be the most powerful predictor of survival. A multicentre study (10 Canadian and 4 US Centres) has enrolled 374 consecutive new peritoneal dialysis patients. The target enrollment is 600 patients. Among these 374 patients are 217 males (58%), 71 patients age > 70 (19%), 106 with diabetic renal disease (28%), 95 with a history of cardiovascular disease (25%) and 60 with serum albumin values < 30 Gm/L (16%). There are 307 white patients (82%) and 26 black patients (7%). The 9 month probabilities were: for patient survival, 96%; for technique survival, 93%; peritonitis-free survival, 68%; exit site infection-free survival, 71%. Final statistical analysis will use multivariate techniques to evaluate the relationships among baseline prognostic factors, nutritional status and clinical outcomes.


Adequacy of peritoneal dialysis: does kt/v have the same predictive value as in HD? A multicenter study. Urea kinetics and the use of KT/V has become a useful tool for assessing adequacy of small solute removal in HD. Clinical data supporting the benefit of urea kinetic analysis in CAPD patients had been lacking. Using the standards of KT/V for hemodialysis, many CAPD patients would be underdialyzed but, most studies show no significant difference in morbidity or mortality between CAPD and HD patients. We studied retrospectively, 102 patients (48 M, 54 F), aged 54.6 +/- 14.8 (range 14-82), on CAPD 24.4 +/- 23.9 months (0-120) from 6 hospitals. Clinical and biochemical parameters, co-morbidity, mortality, and hospital admission rate were registered. During the follow-up (1 year), a significant decrease of residual renal function (Kr) from 1.74 +/- 1.86 to 1.31 +/- 1.67 (p < 0.01) was noticed. The KT/V also decreased from 2.00 +/- 0.47 to 1.89 +/- 0.36 (p < 0.01) without change in BUN or plasma creatinine levels. The normalized protein catabolic rate (NPCR) decreased from 0.98 +/- 0.28 to 0.93 +/- 0.30 (p < 0.05) and serum albumin from 3.7 +/- 0.5 to 3.5 +/- 0.6 (p < 0.001). There was a positive correlation between NPCR and KT/V (r = 0.44, p < 0.05) and between NPCR with serum BUN (r = 0.27, p < 0.05). There was no correlation between KT/V and NPCR neither with hospitalization rate nor clinical symptoms index. The latter, however, showed a positive correlation with the co-morbidity index.(ABSTRACT TRUNCATED AT 250 WORDS)


The place for automated peritoneal dialysis. The progress of automated peritoneal dialysis is initmately linked to the evolution of automated peritoneal delivery systems. The state of the art devices have incorporated computerized programs capable of delivering precise timing and volumes of dialysate and have made possible the delivery of CCPD, NPD, IPD or TPD with either time-controlled or volume-controlled delivery modes. Data storage and telephone transmission to the center have also helped in assessing compliance and documentation of dialysis delivered. The most common indications for automated peritoneal dialysis remain patient preference and the need for partner assistance. However, new indications have emerged from our better understanding of peritoneal dialysis kinetics and the recent emphasis on dialysis prescription and quality assurance.


LFA-1 and ICAM-1 molecule expression in jejunal mucosa from children with autoimmune enteropathy. The expression of adhesion molecules by cells of the small intestinal mucosa was compared in gut biopsies from children with autoimmune small intestinal enteropathy and normal controls and related to HLA-DR expression by the same tissue. Jejunal biopsies were stained by IFL with monoclonal antibodies to LFA-1 (TS1/22 and CD11a/25.3.1) and ICAM-1 (RR1/1 and 84H10) molecules. LFA-1 and ICAM-1 positive cells were observed in the lamina propria in all cases and the counts were increased in autoimmune enteropathy compared with controls. In addition, in 4 of 7 cases of autoimmune enteropathy crypt enterocytes were positives for ICAM-1 when stained with RR1/1 and 3 of the 4 were also positive for LFA-1 when stained with both LFA-1 reagents. We speculate on the role of adhesion molecule expression in autoimmune enteropathy.


Analysis of heart rate variability to assess hemodynamic alterations following induction of anesthesia. Extensive changes in hemodynamics and cardiac rhythm during induction of anesthesia may be mediated by altered responses of the autonomic nervous system to anesthetic agents. Analysis of the power spectrum of the heart rate (PSHR) variability can supply information about the autonomic nervous system, and may be used in order to assess this phenomenon. In this study, 78 patients undergoing coronary artery bypass graft surgery were evaluated. Anesthesia was induced with sufentanil, and neuromuscular blockade with vecuronium, a combination that may cause a decrease in heart rate. Before and after induction of anesthesia, the heart rate (HR), blood pressure (BP), cardiac output (CO), cardiac index (CI), and PSHR components were recorded. PSHR was obtained by using a special algorithm and data acquisition system for real-time spectral analysis. A low-frequency component (LFa, mainly sympathetic) was analyzed from a band of 0.04 Hz to 0.1 Hz. A high-frequency component (RFa, parasympathetic) was identified by the respiratory frequency spectrum. Alterations of the heart rate after induction of anesthesia were defined in order to separate the patient population into two groups: slow heart rate (slow-HR) and stable heart rate (stable-HR). Slow heart rate was defined as a decrease in HR of more than 20% of the baseline value. The variables were analyzed and compared between the slow-HR (n = 25) and stable-HR (n = 53) groups in order to verify the possibility of identifying patients prone to hemodynamic changes after anesthesia induction. There were no differences in preoperative HR, BP, CO, or CI between groups before anesthesia induction.(ABSTRACT TRUNCATED AT 250 WORDS)


Differential diagnosis of HTLV-I-associated myelopathy and multiple sclerosis in Iranian patients. Two Iranian patients with chronic progressive spastic paraparesis and urinary dysfunction were referred to our hospital with the presumptive diagnosis of multiple sclerosis (MS). Routine CSF analysis and magnetic resonance imaging of the two patients were only partially characteristic of MS. Testing for antibodies to human T-cell leukemia virus type I [HTLV-I] in serum using a radioimmune precipitation assay revealed antibodies to HTLV-I in both patients. The infection with HTLV-I was confirmed by polymerase chain reaction (PCR) and liquid hybridization analysis using primers to the tax/rex region and a corresponding probe, demonstrating proviral DNA in peripheral blood mononuclear cells of both patients. On the basis of these findings demonstrating the presence of proviral HTLV-I DNA in the two Iranian patients, the initial diagnosis of MS was corrected to that of HTLV-I-associated myelopathy (HAM). In contrast, several patients with definite MS (nine from Germany, two from Iran) with a relapsing and remitting form of the disease were tested for HTLV-I infection by enzyme-linked immunosorbent assay and PCR, which yielded negative results. However, the mother of one HAM patient was found to be infected with HTLV-I. To support an association between HTLV-I infection and CNS disease in the two HAM patients, we analyzed the production of specific IgG antibodies within the CNS based on a simple enzyme immunoassay for viral IgG antibodies in CSF and serum. In the two HAM patients there was significant intrathecal antibody production directed against HTLV-I, but this was not found in any of the samples from MS patients.(ABSTRACT TRUNCATED AT 250 WORDS)


Balanced efficiencies of splicing and cleavage-polyadenylation are required for mu-s and mu-m mRNA regulation. The relative abundance of the RNAs encoding the membrane (mu-m) and secreted (mu-s) forms of immunoglobulin mu heavy chain is regulated during B cell maturation by a change in the mode of RNA processing. This regulation depends on a competition between two mutually exclusive RNA processing reactions, cleavage-polyadenylation at the microseconds poly(A) site and splicing of the Cmu4 and M1 exons. Previously, the efficiencies of these two reactions were altered independently. When an efficient processing signal replaced the normal suboptimal signals of the mu gene, a single RNA product was produced exclusively. In this report, two efficient signals are combined in a single mu transcript and shown to restore a processing balance such that two mRNAs can once again be alternatively processed from a single RNA precursor. The ratio of the two RNAs generated from these mu genes containing balanced competing strong splice and cleavage-polyadenylation reactions display the expected developmental shift when expressed in B cells and plasma cells. Therefore, the balance between cleavage-polyadenylation and splicing efficiencies is critical to the developmentally regulated expression of mu-s and mu-m mRNA. Also shown here is that the entire mu-m region, including the M1 and M2 exons and the mu-m poly(A) site, can be replaced with SV40 splice and poly(A) sequences. Regulation is maintained in these mu genes, indicating that no specific sequences within the mu-m region are required.