Treatment of mycobacterial exit-site infections in patients on continuous ambulatory peritoneal dialysis.

Exit-site infections (ESIs) are frequently due to gram-positive organisms and occasionally to gram-negative organisms. Initial empiric antibiotic therapy is therefore directed against these organisms until culture reports are available. Two cases of ESI associated with Mycobacterium are here reported. The first patient, a 63-year-old man with type 2 diabetes, recently treated for Staphylococcus epidermidis peritonitis, presented with acute purulent drainage at the catheter exit site, accompanied by pain and erythema. No tunnel abscess was identified by ultrasound. Empiric antibiotic therapy was initiated with ofloxacin and vancomycin. A rapid-growing acid-fast bacillus (AFB) noted four days after culture was eventually identified as Mycobacterium fortuitum. Ofloxacin was continued, vancomycin was discontinued, and clarithromycin was added. The ESI initially showed improvement; therapy was therefore continued for several months. However, cultures remained positive for M. fortuitum, and the catheter was removed 5 months after therapy was initiated. The second patient, a 28-year-old woman, presented with severe pain and tenderness at the exit site without erythema or drainage. Empiric therapy with cefazolin, gentamicin, and cephalexin was initiated. Gram-positive cocci and an AFB were identified from the exit-site culture, and antibiotics were initially changed to clarithromycin, trimethoprim/sulfamethoxazole, and ofloxacin. The organisms were subsequently identified as M. chelonae-M. abscessus complex and coagulase-negative Staphylococcus. The patient continued to improve after 3 weeks of antibiotic therapy. However, despite the initial improvement in the ESI, the M. chelonae-M. abscessus complex continued to grow, and amikacin was added intravenously. Despite continued treatment, the ESI did not resolve, and the catheter was removed after 4 months of therapy. Despite unusual exist-site infections with rapidly growing AFBs, both patients continued continuous ambulatory peritoneal dialysis (CAPD) while undergoing treatment for ESI. Catheters were left intact, as improvement was initially seen with no evidence of tunnel infection or peritonitis. Rapid-growing AFB should be considered another possible causative agent for ESI. Two cases of atypical mycobacterial exit-site infection are presented to illustrate the difficulties in managing this complication of peritoneal dialysis. Ofloxacin--or other quinolones--may provide a better spectrum of coverage when choosing empiric therapy in patients presenting with ESI.

Viral hepatitis as a cause of renal disease.

Viral hepatitis has become a recognized cause of both acute and chronic renal disease. Acute and chronic viral infections may result in formation of immune complexes that can become deposited in the glomerular capillary basement membrane, stimulating both cytokine production and complement activation and producing a variety of glomerular lesions. Chronic viral infections may also result in production of mixed polyclonal IgG and monoclonal IgM cryoglobulins, which result in systemic vasculitic syndromes that also involve the kidney. Glomerular injury through these mechanisms may become clinically manifested as either acute glomerulonephritis or the nephrotic syndrome. Because of the worldwide prevalence of hepatitis B and C infections, they are important public health problems that may lead to a variety of important renal diseases. Further understanding of the mechanisms by which these viruses induce injury will allow more effective treatment strategies to reverse the renal diseases induced by hepatotropic viral infection.

Persistent lupus activity in end-stage renal disease.

Clinical and serological activity of systemic lupus erythematosus (SLE) has been reported to dramatically improve in patients who develop end-stage renal disease (ESRD). At Tulane University Medical Center, most patients with SLE and ESRD continue to have evidence of disease activity. A retrospective study of lupus activity was therefore performed in 19 patients with SLE, who were either undergoing dialysis or had undergone transplantation between 1988 and 1994, to determine disease activity before and a mean follow-up of 3 years after ESRD. There were seven hemodialysis patients, five peritoneal dialysis patients, and seven transplant recipients in the study population. Clinical events recorded to evaluate disease activity as indicators of serological activity were malar rash, ulcers, alopecia, arthritis, myositis, pleuritis, pericarditis, fever, cerebritis, and vasculitis. The following studies were recorded as measures of serological activity: leukocyte count, platelet count, serum complement 3 level, and anti-double-stranded DNA level. Disease activity was measured by using the SLE Disease Activity Index and the requirement for immunosuppressive medications. Clinical event rates for alopecia, arthritis, myositis, pleuritis, pericarditis, fever, and vasculitis were greater after ESRD but not to statistical significance. Serological studies showed little change in the dialysis patients before and after ESRD; however, there was a tendency for lupus serological results to improve after transplantation. When all event rates were combined, there was a statistically significant greater incidence of lupus activity after both hemodialysis and peritoneal dialysis (P < 0.01) but not after renal transplantation. Fifty-eight percent of the patients undergoing dialysis died, either during the study period or within a 5-year follow-up, all of whom had clinically active lupus. This study therefore shows that lupus activity may persist in patients with ESRD. It is speculated that the study population, 84% of whom were black women, may represent a subgroup of patients with lupus in whom the disease remains active, even after they have developed ESRD.

A young man with acute renal failure.

A 34-year-old man, over a 2-week period, had an increase in serum creatinine from 5.0 mg/dL to 11.0 mg/dL. A renal biopsy was performed.

Penile prostheses in the management of impotence in patients with end-stage renal disease.

Erectile dysfunction, which has multifactorial causes including uremia, diabetes mellitus, hypertension, vascular insufficiency, autonomic neuropathy, and psychogenic pathology, occurs in a majority of patients with end-stage renal disease. After evaluation in the Sexual Dysfunction Clinic to exclude reversible disorders that may cause erectile dysfunction, hormonal supplementation, vacuum erection devices, and a self-injection program are offered to patients. Due to concern about patient's immunocompromised status, penile prostheses have not been considered appropriate therapy for those on dialysis or for renal transplant recipients. We report our 8-year experience with penile prostheses in 12 ESRD/renal transplant patients. Eleven patients have maintained their prostheses. Three patients had prostheses with mechanical failures that required reimplantation, and one prosthesis became infected and was explanted. Penile prostheses can be successfully implanted without excessive risk of infection in patients with erectile dysfunction resulting from end-stage renal disease.

Renal biopsy in a young man with hematuria.

A 24-year-old man was referred for evaluation of microscopic hematuria. Urologic work-up was unremarkable. A renal biopsy was performed.

Renal biopsy in a child with nephrotic syndrome.

A 6-year-old girl with nephrotic syndrome was treated with prednisone, without response. A renal biopsy was obtained. Following the format used at the Tulane Renal Biopsy Conferences, the clinical presentation, differential diagnosis and clinical discussion in this young patient will be presented first. The second part will include the renal biopsy findings, the final diagnosis and the pathology discussion.

Evaluation of lupus nephritis during pregnancy by renal biopsy.

Patients with lupus nephritis frequently exhibit increasing proteinuria, hypertension and deterioration of renal function due to either active lupus nephritis, chronic lupus nephritis and/or superimposed preeclampsia during pregnancy. Percutaneous renal biopsies were therefore performed in 3 women with systemic lupus erythematosus during pregnancy and immediately postpartum in a fourth woman to evaluate their renal disease during pregnancy. Mean serum creatinine at renal biopsy was 2.9 mg/dl, with a mean creatinine clearance of 66 ml/min and protein excretion of 5.3 g/day. All patients had grade IV lupus nephritis and received pulse methylprednisolone immediately; 3 received cyclophosphamide. All 3 patients with crescent formation developed endstage renal disease within 3 years. The fourth patient has normal renal function 3 years after biopsy. Percutaneous renal biopsies during pregnancy in women with lupus nephritis provide an accurate histopathologic diagnosis and are important in providing appropriate therapy, counseling and prognosis.

Neisseria meningitidis peritonitis in a CAPD patient: first case report and review of the literature.

Only 15 cases of any etiology of Neisseria meningitidis peritonitis have been reported in the world literature since the first case in 1917. We report the first case in a continuous ambulatory peritoneal dialysis (CAPD) patient presenting with abdominal pain and cloudy peritoneal dialysis fluid. A lumbar puncture was normal. The patient died despite therapy with ceftriaxone. Autopsy confirmed this was a case of primary N. meningitidis peritonitis. Of the 15 cases of N. meningitidis reported as a cause of peritonitis, 9 patients were less than age 35 with no underlying diseases. Five cases were associated with cirrhosis or alcohol abuse. Two cases were associated with meningitis, and 1 patient was on steroid therapy for systemic lupus erythematosus. Nine of 15 patients recovered. In conclusion, N. meningitidis should be considered as another rare cause of peritonitis in patients on CAPD.

Treatment of end-stage renal disease due to lupus nephritis: comparison of six patients treated with both peritoneal and hemodialysis.

End-stage renal disease (ESRD) is one of the most significant complications of systemic lupus erythematosus (SLE). Previous investigators have evaluated the morbidity and mortality of different renal replacement treatment modalities in these patients. Earlier reports have suggested that the systemic manifestations of SLE diminish, or "burn out," once ESRD occurs. These investigators also suggested that vascular access complications were a significant cause of morbidity and mortality in these patients treated with hemodialysis (HD). A retrospective review of the records of 6 patients with ESRD from lupus nephritis (LN), who received both HD and peritoneal dialysis (PD), was performed to determine if there was a difference in disease activity between treatment modalities, using patients as self-controls. The number of SLE flares was determined by clinical and/or serologic studies, and prednisone dosages compared for each treatment modality. Four of the 6 patients continued to have active SLE after renal replacement therapy was begun. There were no significant differences in the number of SLE flares or prednisone dosages while receiving either treatment modality. While PD eliminates problems associated with vascular access, both HD and PD were effective forms of renal replacement therapy. Most patients in this study continued to have active SLE after commencement of dialysis, with no differences in disease activity noted during HD or PD.

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.

Once weekly subcutaneous erythropoietin is an effective maintenance therapy in the treatment of anemia of end stage renal disease in patients on CAPD.

The efficacy of once weekly subcutaneous erythropoietin (SC EPO) was evaluated by reviewing records of twelve continuous ambulatory peritoneal dialysis (CAPD) patients age 27-66 years after achieving a goal hematocrit (hct) greater than 30%. Patients had a mean hct of 22.8% (range: 19.1-29.5) and were placed on a thrice weekly SC EPO dose of 4000 international units (IU) (37-74 IU/KG, [mean of 57 IU/kg]) until a goal hct greater than 30% was achieved. This hct ranged from 30.8-37% (mean 33.2%) and was achieved in a mean of 11.5 weeks (range: 4.1-29 weeks). Patients were then maintained on the same SC EPO dose given only once weekly. 11/12 (92%) patients have maintained a mean hct of 34% (range: 29-38.4%) on once weekly SC EPO over a mean period of 14 weeks (range: 1.4-36 weeks). The mean serum ferritin was 484; only two patients required parenteral iron dextran therapy. One patient did not reach the goal hct due to poor compliance. There was no significant increase in blood pressure or in serum potassium level. We conclude that SC EPO is effective in treating anemia in these patients and can be given once weekly to maintain a hct greater than 30%.

Changes by two-dimensional echocardiography in the myocardial appearance of patients with end-stage renal disease.

A retrospective study of the clinical and biochemical data of all patients with end-stage renal disease who underwent 2-dimensional echocardiography at Tulane Medical Center between 1982 and 1986 was performed. Complete echocardiographic data were available for comparison in 53 patients. Highly reflective echoes were judged to be present in the myocardium of 81% of the patients. This characteristic is described as a "glistening speckled appearance." Patients with this characteristic had significantly greater left ventricular mass index (p = 0.0021).