Splenic abscess and peritonitis in a continuous ambulatory peritoneal dialysis (CAPD) patient

A 26-year-old female was on continuous ambulatory peritoneal dialysis (CAPD) because of diabetic end-stage renal failure. She developed an acute peritonitis that relapsed repeatedly despite appropriate antibiotic treatment. Investigations showed the presence of a splenic abscess, and splenectomy and peritoneal cannula removal were required. The patient died of myocardial infarction two weeks postoperatively. This is the first recorded case of peritonitis secondary to splenic abscess in a CAPD patient. Autopsy findings suggest that the abscess developed from infection of a splenic infarct.     

Longitudinal study of peritoneal membrane function in continuous ambulatory peritoneal dialysis: relationship with peritonitis and fibrosing factors.

BACKGROUND: The peritoneal equilibration test (PET) is a useful assessment of peritoneal function in continuous ambulatory peritoneal dialysis (CAPD) patients. However, the natural course of longitudinal change in peritoneal transport is not well defined. PATIENTS: We studied 105 unselected CAPD patients. Average age at enrollment was 50.7 +/- 11.3 years. METHODS: A PET was performed at enrollment. Peritoneal transport was expressed as dialysate-to-plasma creatinine ratio at 4 hours (DIP). Fibrosing factors and mesothelial cell markers, including TGFbeta, epidermal growth factor (EGF), platelet-derived growth factor (PDGF), hyaluronan, and cancer antigen 125 (CA125), were measured in overnight peritoneal dialysate effluent (PDE). Patients were followed for two years. Peritonitis episodes were recorded. Severe peritonitis was defined as an episode that required catheter removal or antibiotic therapy for more than 3 weeks. After two years, 75 patients were still alive and on CAPD. RESULTS: The PET was repeated in 64 patients, of whom 35 were male and 9 had diabetes. The change in D/P over two years was represented as AD/P. No significant change in peritoneal transport was seen after two years (D/P: 0.56 +/- 0.12 vs 0.55 +/- 0.13). A centripetal pattern of change in D/P was observed. The deltaD/P had normal distribution and was inversely correlated with D/P at baseline (r = -0.427, p < 0.005). Both results suggest a regression-to-mean phenomenon. The deltaD/P had no significant correlation with the total number of peritonitis episodes (Spearman r = 0.052, p = 0.74), but after severe peritonitis, affected patients had higher deltaD/P than patients who experienced no severe infection (0.040 +/- 0.136 vs -0.032 +/- 0.120, p < 0.05). For patients with no episodes of severe peritonitis (n = 47), deltaD/P was weakly correlated with baseline TGFbeta level (r = -0.506, p < 0.01). No correlation was seen between the levels of other fibrosing factors and change in peritoneal transport. CONCLUSIONS: Our findings suggest that the centripetal change of peritoneal transport probably reflects a regression-to-mean phenomenon. Peritoneal transport increases after severe peritonitis. The role of TGFbeta levels in PDE with regard to longitudinal change in peritoneal transport requires further study.     

Peritoneal accumulation of AGE and peritoneal membrane permeability.

BACKGROUND: In continuous ambulatory peritoneal dialysis (CAPD), the peritoneal membrane is continuously exposed to high-glucose-containing dialysis solutions. Abnormally high glucose concentration in the peritoneal cavity may enhance advanced glycosylation end-product (AGE) formation and accumulation in the peritoneum. Increased AGE accumulation in the peritoneum, decreased ultrafiltration volume, and increased peritoneal permeability in long-term dialysis patients have been reported. AIM: The purpose of the study was to evaluate the relation between peritoneal membrane permeability and peritoneal accumulation of AGE. METHODS: Peritoneal membrane permeability was evaluated by peritoneal equilibration test (PET) using dialysis solutions containing 4.25% glucose. Serum, dialysate, and peritoneal tissue levels of AGE were measured by ELISA method using polyclonal anti-AGE antibody. Peritoneal biopsy was performed during peritoneal catheter insertion [new group (group N), n = 18] and removal [long-term group (group LT), n = 10]. Peritoneal catheters were removed due to exit-site infection not extended into the internal cuff (n = 6) and ultrafiltration failure (n = 4) after 51.6+/-31.5 months (13 - 101 months) of dialysis. PET data obtained within 3 months after the initiation of CAPD or before catheter removal were included in this study. Ten patients in group N and 4 patients in group LT were diabetic. Patients in group LT were significantly younger (46.5+/-11.1 years vs 57.5+/-1.3 years) and experienced more episodes of peritonitis (3.5+/-2.1 vs 0.2+/-0.7) than group N. RESULTS: Peritoneal tissue AGE level in group LT was significantly higher than in group N, in both nondiabetic (0.187+/-0.108 U/mg vs 0.093+/-0.08 U/mg of hydroxyproline, p < 0.03) and diabetic patients (0.384+/-0.035 U/mg vs 0.152+/-0.082 U/mg of hydroxyproline, p < 0.03), while serum and dialysate levels did not differ between the groups in both nondiabetic and diabetic patients. Drain volume (2600+/-237 mL vs 2766+/-222 mL, p = 0.07) and D4/D0 glucose (0.229+/-0.066 vs 0.298+/-0.081, p < 0.009) were lower, and D4/P4 creatinine (0.807+/-0.100 vs 0.653+/-0.144, p< 0.0001) and D1/P1 sodium (0.886+/-0.040 vs 0.822+/-0.032, p < 0.0003) were significantly higher in group LT than in group N. On linear regression analysis, AGE level in the peritoneum was directly correlated with duration of CAPD (r = 0.476, p = 0.012), number of peritonitis episodes (r = 0.433, p = 0.0215), D4/P4 creatinine (r = 0.546, p < 0.027), and D1/P1 sodium (r = 0.422, p = 0.0254), and inversely correlated with drain volume (r = 0.432, p = 0.022) and D4/D0 glucose (r = 0.552, p < 0.0023). AGE level in the peritoneal tissue and dialysate were significantly higher in diabetics than in nondiabetics in group LT, while these differences were not found in group N. Serum AGE level did not differ between nondiabetics and diabetics in either group N or group LT. Drain volume and D4/D0 glucose were lower and D4/P4 creatinine and D1/P1 sodium higher in diabetics than in nondiabetics in both groups. CONCLUSION: Peritoneal accumulation of AGE increased with time on CAPD and number of peritonitis episodes, and was directly related with peritoneal permeability. Peritoneal AGE accumulation and peritoneal permeability in diabetic patients were higher than in nondiabetic patients from the beginning of CAPD.     

Dialysis efficiency in continuous ambulatory peritoneal dialysis patients treated with erythropoietin.

OBJECTIVE: To determine the effect of subcutaneous erythropoietin treatment on dialysis efficiency in continuous ambulatory peritoneal dialysis (CAPD) patients. DESIGN: Dialysis efficiency, platelet and white cell aggregation, and red cell deformability were measured monthly for six months in nine anaemic CAPD patients treated with erythropoietin, and on a single occasion in seven control CAPD patients with intrinsically high haemoglobin concentrations. SETTING: Renal dialysis unit. PATIENTS: Nine patients stable on CAPD for a minimum of six months and with haemoglobin concentrations less than 8.5 g/dl were treated with erythropoietin. Seven CAPD patients matched for age and renal function, with haemoglobins greater than 9.0 g/dl served as controls. RESULTS: Daily peritoneal clearances and net ultrafiltration volumes were unchanged when haematocrit increased from 25.0 +/- 2.2% to 36.5 +/- 3.5%. Spontaneous whole blood platelet aggregation was significantly increased from week twelve (pre-treatment aggregation 46 +/- 23%; 12 weeks: 67 +/- 19%, p less than 0.05; 16 weeks: 64 +/- 19%, p less than 0.01; 20 weeks: 71 +/- 16%, p less than 0.01; 24 weeks: 73 +/- 10%, p less than 0.01). CONCLUSIONS: The increase in haematocrit and platelet aggregation associated with erythropoietin treatment did not affect peritoneal clearances or ultrafiltration capacity.     

Characterization of subtypes of hypertension in CAPD patients by cyclic guanosine monophosphate.

OBJECTIVE: While most hypertensive patients with end-stage renal disease normalize high blood pressure with fluid removal by continuous ambulatory peritoneal dialysis (CAPD), there is a significant proportion of CAPD patients whose blood pressure can be controlled only by antihypertensive drugs. METHOD AND PATIENTS: To study the hypothesis that such patients are still volume overloaded, we used plasma cyclic guanosine monophosphate (cGMP) as a marker for hydration status. Thirty-two CAPD patients were divided into 3 groups: group 1, normotensive patients (n = 12); group 2, hypertensive patients who normalized their blood pressure with fluid removal (n = 12); group 3, hypertensive patients whose blood pressure was refractory to intensified fluid removal (n = 8). RESULTS: Mean cGMP levels were significantly higher in dialysis-sensitive hypertension (27 +/- 5 pmol/mL) than in dialysis-refractory hypertension (15 +/- 2 pmol/mL), or in normotensive patients (13 +/- 4 pmol/mL). Reduction of excess fluid in volume overloaded hypertensive CAPD patients resulted in a normalization of cGMP levels (14 +/- 8 pmol/mL), but did not affect this volume marker in patients with dialysis-resistant hypertension (10 +/- 4 pmol/mL). CONCLUSION: Plasma cGMP levels are elevated in volume overload-induced hypertension complicating CAPD. Hypertensive CAPD patients whose plasma cGMP levels are within normal limits have raised blood pressure refractory to volume removal. Our findings are consistent with the hypothesis that inadequate removal of excess volume plays a major role in a subset of patients with CAPD hypertension.     

Tenckhoff catheter replacement or intraperitoneal urokinase: a randomised trial in the management of recurrent continuous ambulatory peritoneal dialysis (CAPD) peritonitis

A randomised trial, comparing Tenckhoff catheter replacement as a one-stage procedure and i.p. urokinase, was undertaken in the management of recurrent continuous ambulatory peritoneal dialysis (CAPD) peritonitis. In addition to appropriate i.p. antibiotic treatment, 17 patients received i.p. urokinase (5000 i.u.) on the second and fourth days of antibiotic treatment, and 14 patients underwent CAPD catheter replacement. An additional six patients also underwent catheter replacement following the recurrence of peritonitis after urokinase treatment. The subsequent recurrence rate of peritonitis following CAPD catheter replacement (5%) was significantly less than after urokinase (41%) (p less than 0.001). Fourteen patients remained free of peritonitis for at least three months after catheter replacement, and five patients were peritonitis-free following urokinase for this period.     

A retrospective study of seven cases of Candida parapsilosis peritonitis in CAPD patients: the therapeutic implications.

BACKGROUND: Candida peritonitis accounts for the majority of fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD), but the Candida species were not routinely subtyped in previous studies.The clinical course and the outcome of Candida parapsilosis peritonitis remain unclear. OBJECTIVE: To study the clinical course and outcome of C. parapsilosis peritonitis in CAPD patients. SETTING: Peritoneal dialysis unit in a regional hospital. PATIENTS AND DESIGN: A retrospective study on seven cases of C. parapsilosis peritonitis occurring in a single center over 3 years. RESULTS: The 7 patients included 4 males and 3 females. Their mean age was 62 +/- 11.5 years. Two (29%) were diabetic. Three (43%) had a history of preceding peritonitis and 5 (71 %) had received broad spectrum antibiotic within the previous 1 month. All presented with cloudy dialysate, abdominal pain, and fever. The mean dialysate white cell count was 300 +/- 168/mm3 with a predominance of neutrophils (81.4% +/- 13.1%).The mean time from onset of symptoms to diagnosis was 5.7 +/- 3.1 days. All had been treated with immediate catheter removal within 24 hours of diagnosis and antifungal therapy, including oral fluconazole, intravenous (IV) amphotericin, or their sequential combination. Environmental samplings were negative for C. parapsilosis. The overall complication rate was exceptionally high (71%), with three (43%) complicated by abscess formation requiring surgical drainage, one peritoneal adhesion (14%), and one mortality (14%). In the end, only two (29%) could resume CAPD. CONCLUSIONS: The outcome of this study group appeared worse than those previously described in the literature, and the optimal treatment for this group of patients remains unclear.     

Recurrent infection and catheter loss in patients on continuous ambulatory peritoneal dialysis.

OBJECTIVE: To elucidate the factors leading to catheter loss from recurrent infection in patients on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: All catheters removed from patients were prospectively examined for infection. SETTING: CAPD unit in large tertiary-care general hospital. PATIENTS: Sixty-five consecutive patients undergoing catheter removal for whatever cause; 20 catheters rejected because of desiccation or contamination in transit. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Micro-organisms linked to catheter removal; their locations on removed catheters. RESULTS: Of 45 catheters removed between January 1994 and August 1995, 26 were infected: 13/26 infections were caused by Staphylococcus aureus and 7/26 by Pseudomonas aeruginosa. In only one case was S. epidermidis associated with catheter removal. The most striking finding was that the inner cuff harbored large numbers of the infecting organisms, even when antibiotics had eradicated them from the peritoneal cavity and exit site, where present, and the catheter lumen. CONCLUSION: The importance of S. aureus and Ps. aeruginosa rather than S. epidermidis in catheter loss due to relapsing infection is confirmed. Persistence of the causative organisms in the inner cuff is a likely explanation for relapse after treatment, and might be due to the predominantly intraperitoneal administration of antibiotics. A clinical trial of the effect on catheter retention of empirical use of systemic or oral agents that give high tissue levels and are active against intracellular micro-organisms, along with recommended intraperitoneal regimens, is indicated.     

Fungal peritonitis complicating peritoneal dialysis: report of 27 cases and review of treatment

The clinical features, treatment and outcome of 27 cases of fungal peritonitis were studied. Twenty-one cases occurred in patients receiving CAPD and six in patients on intermittent peritoneal dialysis. Twenty-five cases were due to Candida spp., one was due to Trichosporon spp. and in one, both Candida and Trichosporon and an unidentified acid-fast bacillus were isolated. Clinical features of fungal peritonitis and bacterial peritonitis were the same. A direct comparison with patients without fungal peritonitis failed to reveal an increased incidence of diabetes mellitus. However, a history of recent bacterial peritonitis and antibiotic treatment was frequently obtained. We found that the combination of oral ketoconazole and intraperitoneal miconazole is successful in treating fungal peritonitis complicating peritoneal dialysis but catheter removal and replacement is often necessary. Analysis of the relationship between clinical outcome and various treatment strategies in cases reported in the literature and in our own showed that an initial trial of antifungal drugs consisting of oral ketoconazole and i.p. 5-fluorocytosine or miconazole is warranted in most cases before contemplating catheter removal.     

Moxalactam kinetics during continuous ambulatory peritoneal dialysis after intraperitoneal administration.

Moxalactam kinetics during continuous ambulatory peritoneal dialysis (CAPD) was followed in eight patients after a single intraperitoneal dose of 1 g. Approximately 60% of the dose was absorbed after a dwell time of 4 h. Dialysis solutions were exchanged at 4-h intervals with an overnight dwell of 8 h. The mean (+/- standard deviation) elimination half-life was 13.2 +/- 2.9 h, and the mean apparent volume of distribution was 0.22 +/- 0.08 liters/kg. Mean total clearance was 11.5 +/- 2.4 ml/min, with a mean dialysis clearance of 2.3 +/- 0.5 ml/min. The maximum concentration in plasma ranged from 24.5 to 54.1 micrograms/ml. Moxalactam concentrations in the peritoneal dialysis fluid were above 80 micrograms/ml during the first exchange and above 2 micrograms/ml for a further three exchanges. A suggested intraperitoneal dose regimen for patients undergoing CAPD is 1 g initially, followed by 15 to 25% of the recommended dose for normal patients given at the same time intervals, or 30 to 50% of the recommended dose at twice the usual intervals. Moxalactam is suggested for initial treatment of peritonitis in CAPD patients who do not have ready access to the antibiotic of choice.     

Continuous ambulatory peritoneal dialysis is responsible for an increase in plasma norepinephrine.

OBJECTIVE: To investigate the reason for increasing norepinephrine (NE) levels reported in continuous ambulatory peritoneal dialysis (CAPD) patients. METHODS: Norepinephrine was measured in the plasma and peritoneal dialysate of CAPD patients (n = 22) and in the plasma and the urine of healthy subjects (n = 20). It was also measured in the plasma of patients with chronic renal failure (CRF) (n = 15) and patients on hemodialysis (HD) (n = 15). RESULTS: It was found that NE was increased in CAPD patients compared with healthy individuals (687+/-221 pg/mL vs 199+/-25 pg/mL, p < 0.01).The daily removal of NE from the peritoneum of CAPD patients was lower compared with the amount of NE excreted in the urine of healthy subjects. Plasma NE increased after infusion of peritoneal dialysate. In 15 new patients on CAPD, it was found that NE plasma levels increased from 329+/-67 pg/mL before initiation of dialysis, to 584+/-173 pg/mL after 12 months of treatment (p < 0.01). Finally, plasma NE in CAPD patients (687+/-221 pg/mL) was significantly higher compared with the already increased levels in patients on HD or with CRF (406+/-143 pg/mL and 378+/-142 pg/mL, respectively). CONCLUSIONS: It is concluded that CAPD in patients with end-stage renal disease is responsible for a progressive increase of plasma norepinephrine.     

The effect of body weight on CAPD related infections and catheter loss

CAPD related infections and catheter loss continue to be the major problems facing the peritoneal dialysis patient. Few risk factors for infections and catheter loss have been identified. We hypothesized that overweight and underweight patients may be at increased risk for infections and catheter related problems. We examined the effect of the patient's weight at the start of peritoneal dialysis on the subsequent peritonitis and catheter infection rates, as well as catheter loss. Weight was expressed as a percentage of ideal body weight (IBW). Those patients who were more than 110% of IBW were considered to be overweight, 90 to 110% of IBW normal and less than 90%, underweight. An equivalent percentage of patients were overweight and underweight at the initiation of peritoneal dialysis (55/228, 24% for both groups). Overweight, normal, and underweight patients had peritonitis rates of 1.0, 0.9, and 0.8 episodes/y and catheter infection rates of 1.1, 1.2, and 0.8 episodes/y, respectively. Despite these similar rates, catheter loss due to infectious complications was greatest in the overweight group and least in the underweight group (p less than 0.05). No obvious explanation for the difference in catheter loss rate was found. Neither S. aureus nor P. aeruginosa infections occurred more frequently in the overweight patients. However, S. aureus infections more often led to catheter loss in the overweight patients. Catheter loss due to catheter leaks and failure to drain was similar in the three groups of patients. We conclude that deviation from ideal body weight at the initiation of dialysis is not a risk factor for CAPD related infections.(ABSTRACT TRUNCATED AT 250 WORDS)     

CAPD in patients with autosomal dominant polycystic kidney disease.

OBJECTIVE: To investigate whether there are specific complications to continuous ambulatory peritoneal dialysis (CAPD) in patients with autosomal dominant polycystic kidney disease (ADPKD) due to defects in various wall structures--causing hernia and diverticulitis--and to enlarged kidneys. DESIGN: The clinical experience of CAPD in 26 patients with ADPKD, treated for 11+/-6 months, was studied in retrospect and compared with that of 26 contemporary controls. Medical records were reviewed with respect to survival in this treatment form and any complication. Peritoneal dialysis capacity (PDC), as measured in 21 ADPKD patients and 20 controls, was also evaluated. SETTING: University Hospital. RESULTS: Before initiation of CAPD, enlarged kidneys necessitated nephrectomy in 2 of 26 ADPKD patients; both cases were registered as preparation for transplantation, not for CAPD. Survival in CAPD was similar in ADPKD patients and controls. Hernia was present in 4 ADPKD patients and 2 controls, and required transfer to hemodialysis in 1 patient from each group, temporarily. The incidence of peritonitis was 1 per 20 months in ADPKD patients versus 1 in 27 months in the controls, not significantly different. Peritonitis was caused by colonic bacteria in similar numbers. Residual renal function was 1.9 2.1 mL/min per 1.73 m2 in ADPKD patients versus 1.9+/-1.4 mL/min per 1.73 m2 in the controls. No difference was detected in any of the variables measured by PDC. CONCLUSION: There were no specific problems related to ADPKD.     

Twenty-four hour hormonal and metabolic profiles in uraemic patients before and during treatment with continuous ambulatory peritoneal dialysis

Circulating intermediary metabolite and hormone concentrations were measured at intervals over 24 h in five uraemic patients before starting dialysis and after 3 months' treatment with continuous ambulatory peritoneal dialysis (CAPD) and in 13 non-uraemic normal controls. Fasting and postprandial glucose concentrations were significantly raised in uraemic patients undialysed and on CAPD but 24 h mean (+/- SEM) levels fell from 6.63 +/- 0.40 to 6.00 +/- 0.26 mmol/l (P less than 0.02) after 3 months' dialysis despite peritoneal glucose absorption. Insulin levels were raised in uraemic patients but were unchanged by CAPD. Uraemia was associated with raised levels of the gluconeogenic precursors lactate and alanine and a further rise in fasting and 24 h mean alanine concentrations occurred with CAPD. Fasting total ketone body concentrations were raised in undialysed uraemic patients but concentrations were suppressed throughout the 24 h in CAPD subjects. Fasting triglyceride concentrations were increased in uraemic subjects and mean 24 h levels rose by 30% from 1.55 +/- 0.42 mmol/l before dialysis to 2.02 +/- 0.59 mmol/l during CAPD. Non-esterified fatty acid concentrations were low in uraemic patients and remained low during CAPD. Undialysed and dialysed uraemic patients displayed raised plasma glucagon concentrations throughout the 24 h, suppression of the normal nocturnal secretion of growth hormone and raised mean cortisol levels, which were 23% (CAPD) to 57% (undialysed) higher than in normal controls. The endocrine and metabolic abnormalities of uraemia are not fully corrected by CAPD. Many of the additional changes observed during CAPD reflect an adaptation to the constant absorption of peritoneal glucose.     

Double guidewire method: a novel technique for correction of migrated Tenckhoff peritoneal dialysis catheter.

Twenty-two consecutive patients with a continuous ambulatory peritoneal dialysis (CAPD) catheter malfunctioning due to catheter migration were treated with a novel radiological manipulation technique, the "double guidewire method." The first guidewire is used to correct the direction of the catheter tip and the second wire is used to anchor the CAPD catheter so that an ideal course of the catheter can be maintained during removal of the first guidewire. Immediate catheter repositioning was achieved in 19 of 22 patients, and durable repositioning success was achieved in 13 patients. In conclusion, the "double guidewire method" is a simple but effective technique for prolonging CAPD catheter life in patients with malfunction due to catheter migration.     

Contribution of lymphatic absorption to loss of ultrafiltration and solute clearances in continuous ambulatory peritoneal dialysis.

The contribution of peritoneal cavity lymphatic absorption to ultrafiltration kinetics and solute clearances in continuous ambulatory peritoneal dialysis was evaluated in patients with normal (group 1) and high (group 2) peritoneal permeability X area during 4-h exchanges using 2 liters 2.5% dextrose dialysis solution with 30 g added albumin. Cumulative lymphatic drainage in all continuous ambulatory peritoneal dialysis (CAPD) patients averaged 358 +/- 47 ml per 4-h exchange and reduced cumulative net transcapillary ultrafiltration at the end of the exchange by 58 +/- 7.2%. The peak ultrafiltration volume was observed before osmotic equilibrium between serum and dialysate was reached and occurred when the net transcapillary ultrafiltration rate had decreased to equal the lymphatic absorption rate. Thereafter the lymphatic absorption rate exceeded the net transcapillary ultrafiltration rate, and intraperitoneal volume decreased. Extrapolated to 4 X 2 liters, 2.5% dextrose, 6-h exchanges per d, lymphatic drainage reduced potential daily net ultrafiltration by 83.2 +/- 10.2%, daily urea clearance by 16.9 +/- 1.9%, and daily creatinine clearance by 16.5 +/- 1.9%. Although lymphatic absorption did not differ between the two groups, lymphatic drainage caused a proportionately greater reduction in net ultrafiltration in group 2 (P less than 0.025), because these patients had more rapid dialysate glucose absorption (P less than 0.05) and less cumulative transcapillary ultrafiltration (P less than 0.01). These findings indicate that cumulative lymphatic drainage significantly reduces net ultrafiltration and solute clearances in CAPD and that ultrafiltration failure in CAPD occurs when daily lymphatic absorption equals or exceeds daily transcapillary ultrafiltration. Reduction of lymphatic absorption may provide a means for future improvement in the efficiency of CAPD.     

Prevalence and management of hernias in peritoneal dialysis patients.

OBJECTIVES: The aim of this study was to assess the prevalence of hernias before and after the start of continuous ambulatory peritoneal dialysis (CAPD) in patients with end-stage renal disease, and to evaluate the result of a proposed surgical treatment. DESIGN: Prospective observational study. SETTING: University hospital. PATIENTS: 122 patients who started CAPD from 1994 to 2000; 26 hernias were diagnosed in 21 (17.2%) patients. MAIN OUTCOME MEASURES: Finding of hernias; morbidity associated with catheter insertion and hernia repair; recurrence of hernias. Results: 19 hernias were detected in 15 patients (12.3%) before they began CAPD; only 7 hernias were observed while on CAPD. Umbilical (61.5%) and inguinal (26.9%) hernias were the most common. Multiple hernias were detected in 4 patients. Simultaneous repair of hernia and catheter insertion was performed in patients with pre-existing hernias. Under local anesthesia, most patients were operated on with surgical techniques of tension-free hernioplasty using a polypropylene mesh. Only mild post-operative complications were recorded: 3 seromas and 1 hematoma. No fluid leakage was found in our series. There were no long-term complications (infection or recurrence) related to the mesh. CONCLUSIONS: 73% of hernias in peritoneal dialysis patients occur before starting dialysis. Hernia problems in these high-risk patients can be safely solved using a careful technique with application of tension-free hernioplasty. Most may be repaired under local anesthesia with simultaneous catheter insertion.     

Pharmacokinetics of aztreonam administered i.p. in continuous ambulatory peritoneal dialysis (CAPD) patients

The pharmacokinetics of Aztreonam (AZT) administered i.p. in six stable patients undergoing continuous ambulatory peritoneal dialysis (CAPD) for end-stage renal disease (ESRD) were studied. One gram of AZT was added into a 2 L bag of dialysate (Medital-Bieffe) just prior to infusion into the peritoneal cavity. The dwell time was 8 h. The serum maximum concentration of AZT was 42.5 +/- 12.4 mg/L (mean +/- SD), achieved in 4.6 +/- 1.0 h. The elimination half-life was 2.4 +/- 0.8 h, almost equal to that found in normal subjects (1.7-2 h). The pharmacokinetic parameters of elimination, as elimination rate constant and clearance of AZT from peritoneal cavity were found 0.305 +/- 0.101 h-1 and 10.05 +/- 3.7 mL/min, respectively, while the bioavailability via the peritoneal membrane was 90.8 +/- 3.05% of administered dose. It is concluded that AZT is eliminated from dialysate at a high rate after i.p. administration and its dialysate and serum levels exceed the MIC for the majority of sensitive organisms including Pseudomonas species. Aztreonam appears to be a potentially useful antibiotic for CAPD peritonitis.     

High-performance liquid chromatographic characterization of neurophysins in chronic renal failure

Levels of immunoreactive (IR) oxytocin (OT)-associated or estrogen-stimulated neurophysin (ESN) and vasopressin-associated or nicotine-stimulated neurophysin (NSN) were measured in plasma of patients with chronic renal failure before and after hemodialysis (HD) and intermittent peritoneal dialysis (IPD), and during continuous ambulatory peritoneal dialysis (CAPD). ESN-IR in 17 patients before HD was 24.4 +/- 2.7 ng/ml (mean +/- SEM) and increased after HD to 33.2 +/- 4.1 ng/ml (P less than 0.001). ESN-IR in 17 patients with CAPD was 15.2 +/- 3.4 ng/ml, significantly lower than in patients undergoing HD, P less than 0.001. In patients receiving IPD (n = 6), ESN was 11.6 +/- 3.7 ng/ml and did not change significantly after IPD. Levels of ESN in patients with renal failure were increased compared with levels in normal individuals, 1.0 +/- 0.1 ng/ml. Levels of ESN were not correlated with laboratory parameters that may be abnormal in renal failure. NSN levels in 16 of 17 patients undergoing HD were 3.2 +/- 0.34 ng/ml and in 14 of 17 patients with CAPD were 2.9 +/- 0.4 ng/ml, respectively. ESN before HD (r = 0.63, P less than 0.01), after HD (r = 0.85, P less than 0.001), and in patients with CAPD (r = 0.83, P less than 0.001) and IPD (r = 0.81, P less than 0.05) correlated significantly with an OT-like peptide previously found to be increased in renal failure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of erythropoietin in continuous ambulatory peritoneal dialysis patients: comparison between intravenous and intraperitoneal administration.

The administration of recombinant human erythropoietin (rHuEPO) in CAPD patients is usually done subcutaneously. Only a few authors have reported on its intraperitoneal (IP) administration. We compared the effect of IP administration of rHuEPO in CAPD patients to that of intravenous (IV) administration. Ten anemic CAPD patients injected rHuEPO into their dialysis bag once a day, 3 times a week, for 18 weeks. The initial dose was 12,000 U. The dwell time of the exchanges with rHuEPO was about 6 hours. Nine other anemic CAPD patients were treated with IV rHuEPO once a week for 18 weeks. The initial dose was 6000 U. In the IP group the hematocrit rose from 24.04 +/- 2.7% to 33.3 +/- 3.8% (mean +/- SD). In the IV group 2 patients were excluded from the efficiency evaluation. In 7 of the 9 patients in the IV group, the hematocrit rose from 23.27 +/- 2.6% to 32 +/- 5.5% (mean +/- SD). The intraperitoneal administration of rHuEPO in CAPD patients is sufficient in improving anemia, although it requires a much larger dosage to yield the same level of improvement as the one obtained with the intravenous administration. However, in patients on continuous cycling peritoneal dialysis or IP dialysis, a smaller dosage during the prolonged dwell time may be effective.