Prognostic factors in patients with acute liver failure undergoing live donor liver transplantation.

Mortality from acute liver failure (ALF) is high. Live donor liver transplantation (LDLT) is the treatment of choice for ALF in Asia, because cadaveric donors are rare. We sought to review our results in ALF patients with undergoing LDLT at our center. One hundred two LDLTs were performed at our center from April 2002 to November 2007, 15 (14%) because of ALF. Mean (SEM; median, range) follow-up was 1,065 (189; 1400; 3-2046) days. Nine patients (60%) had acute exacerbation of chronic hepatitis B; and 6 (40%) had drug-induced liver injury. Age was 47 (3; 50; 27-65) years. Ten patients (67%) were men. At transplantation, laboratory values were included bilirubin, 449 (35) micromol/L; creatinine concentration, 182 (32) mmol/L. The international normalized ratio was 2.4 (0.2). The Model for End-Stage Liver Disease (MELD) score was 34 (2). Both inpatient and long-term mortality was 20% 3 of 15 patients died. The 5-year survival was 80%. Compared with survivors, patients who died had a significantly higher creatinine concentration 289 vs 155 micromol/L, international normalized ratio (3.4 vs 2.1), MELD score (47 vs 32). We conclude that despite being sick with median and mean MELD scores of 32 and 34, 80% of patients with ALF can achieve good long-term survival after LDLT.

Experience of the transplant team is an important factor for posttransplant survival in patients with hepatocellular carcinoma undergoing living-donor liver transplantation.

Living-donor liver transplantation (LDLT) is an effective treatment for patients with unresectable hepatocellular carcinoma (HCC). However, it remains controversial whether expanded listing criteria can be used for LDLT. We aimed to review results of LDLT for patients with HCC at our center. Patients with HCC were accepted for LDLT if there was no extrahepatic spread on computed tomography (CT) and positron emission tomography CT scan. Transarterial chemoembolization was performed before LDLT to control the tumors. Sirolimus or everolimus was used as part of the immunosuppressive protocol for all patients. Over the last 6 years, 35 of the 102 (34%) LDLT were performed at our center for HCC. Age (mean +/- SEM) was 55.3 +/- 1.3 years; 28 patients (80%) were men. Eight (23%) had LDLT performed in 2002 or 2003 (period 1), and 27 (77%) in 2004 to 2007 (period 2). Eleven (31%) were within and 23 (69%) were outside the Milan criteria. After 583 +/- 76 days follow-up, nine (25%) died, three of recurrent HCC. Three-year survival was significantly better in period 2 than in period 1 (90% vs 13%; P < .001). Although the 3-year survival for those within Milan criteria was better than those outside Milan criteria, the difference did not reach statistical significance (86% vs 57%; P = .26). Six (17%) had HCC recurrence, of whom five died. We concluded that reasonable medium-term survival can be obtained for patients with HCC. The experience level of the transplant team seemed to be the most important predictor of patient outcome.

Once-daily intraperitoneal gentamicin is effective therapy for gram-negative CAPD peritonitis.

OBJECTIVE: To report our 3-year experience with the use of once-daily intraperitoneal (IP) gentamicin in the treatment of gram-negative continuous ambulatory peritoneal dialysis (CAPD) peritonitis. DESIGN: A prospective cohort study in prevalent CAPD patients. SETTING: A tertiary care institution. PATIENTS: All CAPD patients who presented with new episodes of peritonitis were studied. At presentation with peritonitis, IP vancomycin and gentamicin were administered as empirical therapy. IP gentamicin was given at a single daily dose of 40 mg/2 L in the overnight bag. The antimicrobial agents were reviewed when the culture results became available. Intraperitoneal ceftazidime was added for the treatment of pseudomonas peritonitis. MAIN OUTCOME MEASURES: Results of microbiological cultures and clinical outcomes of peritonitis were analyzed. RESULTS: Over a 36-month period, 190 episodes of peritonitis were recorded, of which 62/190 episodes (32.6%) isolated gram-negative organisms. The gram-negative organisms isolated were Escherichia coli, 15/62 episodes (24.1%); Pseudomonas aeruginosa, 12/62 episodes (19.4%); Acinetobacter spp, 12/62 episodes (19.4%); Klebsiella spp, 10/62 episodes (16.1%); and others, 13/62 episodes (21.0%). The overall treatment success rate was 66.1%. The treatment success rates were 74.0% if pseudomonas infections were excluded, 76.1% if gentamicin-resistant pathogens were excluded, and 80.5% if both pseudomonas infections and gentamicin-resistant pathogens were excluded. CONCLUSIONS: Once-daily IP gentamicin appears to be effective in the treatment of gram-negative CAPD peritonitis.

A prospective randomized comparison of the Swan neck, coiled, and straight Tenckhoff catheters in patients on CAPD.

Our objective was to study the impact of peritoneal catheter configuration on continuous ambulatory peritoneal dialysis (CAPD)-related infections, mechanical complications, and patient dropout in a prospective randomized trial. Forty consecutive patients who were commencing CAPD were randomized to receive either a double-cuff, Swan neck coiled catheter or a double-cuff, straight Tenckhoff catheter, implanted by surgical technique. There was no significant difference in the peritonitis rate between the two groups. There was a lower rate of exit-site infection in the Swan neck group compared to the straight catheter group (0.29 vs 0.60 episodes/patient-year, p < 0.05). Catheter-tip migration occurred in 3 patients with the straight catheters compared to one patient with the Swan neck catheter. No patient had to discontinue CAPD because of mechanical complications. The number of CAPD patient dropouts was not significantly different between the two groups. The Swan neck configuration resulted in a significant reduction in the rate of exit-site infections. The coiled component of the catheter may lead to fewer episodes of catheter-tip migration. However, catheter configuration did not influence the number of technique failures.

Lipoprotein (a) levels and clinical correlations in CAPD patients.

Dyslipidemia is an important risk factor for atherosclerotic vascular disease. Serum lipoprotein (a) [Lp(a)] has been implicated as an independent atherogenic risk factor. We measured serum (Lp(a) levels in our patients and studied its correlations with other lipoproteins and clinical parameters. All stable patients on continuous ambulatory peritoneal dialysis (CAPD) for more than one month were enrolled in the study. Fasting serum Lp(a), total cholesterol, triglycerides, LDL-cholesterol, HDL-cholesterol, apolipoprotein-A and apolipoprotein-B levels were measured on entering the CAPD program and at 3 monthly intervals. One hundred and nine patients (M/F: 65/44, mean age +/- SD: 59.5 +/- 12.0 years) were studied. Fifty-two patients had diabetes mellitus. Age- and sex-matched normals were used as controls. Serum Lp(a) levels were raised in 54.5% of CAPD patients compared to 18.6% of controls (p < 0.01). There was no significant change in Lp(a) levels over time. Serum Lp(a) levels showed positive and negative correlations with LDL-cholesterol and triglycerides, respectively, but not with age, sex, diabetic status, and serum total cholesterol and albumin levels. Thirty-six of 54 (66.7%) patients with serum Lp(a) levels greater than 30 mg/dL had either coronary, cerebral, and/or peripheral vascular disease compared to 30/55 (54.5%) of patients with serum Lp(a) levels less than 30 mg/dL (p = NS). In conclusion, serum Lp(a) levels were raised in a significant proportion of CAPD patients, but there was no significant association with vascular disease.

Serum tumor markers in patients on dialysis and kidney transplantation.

Tumor markers play an important role in the assessment of patients with some types of malignant tumors. We studied the effects of dialysis and transplantation on the serum levels of five tumor markers; alpha-fetoprotein (AFP), carcino-embryonic antigen (CEA), cancer antigen-125 (CA-125), cancer antigen-19.9 (CA-19.9), and prostate specific antigen (PSA). Serum tumor markers were measured in patients who-had been on dialysis treatment or had a renal transplant for at least one month. Four groups of 30 patients each (hemodialysis, peritoneal dialysis, renal transplant, and normal controls) were studied. Age and sex distribution were comparable between the dialysis and control groups, but the age was significantly younger in the transplant group. Serum AFP and PSA levels were within normal limits in the dialysis and transplant patients. Serum tumor markers, which were raised in the hemodialysis and peritoneal dialysis patients compared to transplant patients and controls, include: CEA (4.5 +/- 2.7 and 5.1 +/- 3.0 vs 1.7 +/- 1.2 and 2.7 +/- 1.2, p < 0.001); CA-125 (41.1 +/- 43.8 and 18.9 +/- 12.7 vs 13.4 +/- 5.7 and 6.1 +/- 4.9, p < 0.001 and p < 0.05); and CA-19.9 (66.0 +/- 60.4 and 66.2 +/- 76.5 vs 20.2 +/- 12.3 and 5.3 +/- 4.5, p < 0.001). Raised CEA, CA-125, and CA-19.9 levels were detected in 37%, 10%, and 53% of peritoneal dialysis patients and 17%, 27%, and 57% of hemodialysis patients. Although the mean serum CEA, CA-125, and CA-19.9 levels were higher in the transplant patients compared to controls.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study of peritoneal dialysis-related infections in CAPD patients with diabetes mellitus.

Data comparing peritoneal dialysis (PD)-related infection rates between diabetic and nondiabetic patients on chronic peritoneal dialysis are conflicting. We carried out a prospective study comparing PD-related infection rates between diabetic and nondiabetic patients treated with continuous ambulatory peritoneal dialysis (CAPD) in our center. All patients commencing CAPD between January 1989 and June 1992 were enrolled into the study. Patients were followed up until death, CAPD dropout, or until December 1992. Data on diabetes mellitus status, Staphylococcus aureus nasal carriage, and PD-related infections were gathered. Infection rates were analyzed using life tables and the negative binomial test. One hundred and seven diabetic patients and 72 nondiabetic patients were studied. Patients with diabetes mellitus were not at increased risk of being S. aureus nasal carriers. The peritonitis rate was significantly higher in the diabetic group (1.2 vs 0.8 episodes/patient/year, p < 0.05). The exit-site and tunnel infection, catheter loss, and patient dropout rates were not significantly different between the two groups. Life-table analysis did not show a significant difference in the time to first episode of peritonitis and catheter-related infection.

Isolation of organisms in CAPD peritonitis: a comparison of two techniques.

The identification of organisms is important in the treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. We compared two techniques for isolating organisms in CAPD peritonitis. Clinical and microbiologic data on all episodes of peritonitis from 1991-1993 were prospectively recorded. The isolation of organisms from 77 episodes of peritonitis was done using the conventional centrifugation culture method from 1991-1992; the isolation of organisms from 121 episodes of peritonitis was done using the BACTEC method from 1992-1993. The total culture-positive rates were 75% for the BACTEC technique and 58% for the conventional technique (p = 0.05), with a higher isolation rate for gram-negative organisms (36% vs 18%, p < 0.05). In the isolation of organisms from new episodes of peritonitis, the culture-positive rates were significantly higher for the BACTEC than for the conventional technique (82% vs 55%, p < 0.01). The recovery rates of organisms for both techniques were similar for relapse peritonitis. The treatment outcomes of CAPD peritonitis for the two technique groups, and for the culture-positive and culture-negative groups were not significantly different. In conclusion, the BACTEC method yielded a higher rate of positive cultures for CAPD peritonitis, but did not affect treatment outcome of the infections.

Staphylococcus aureus CAPD-related infections are associated with nasal carriage.

Staphylococcus aureus nasal carriage has been shown to be associated with an increased risk of S. aureus exit-site infections, but its association with peritonitis is less well established. We performed a four-year prospective study to determine the relationship between S. aureus continuous ambulatory peritoneal dialysis (CAPD)-related infections and nasal carriage. All patients who had been started on CAPD from 1989 to 1992 had regular nose cultures. S. aureus nasal carriage was defined as two of three positive nose cultures. A total of 41 carriers and 105 noncarriers were studied. The rates of S. aureus exit-site infection (0.23 vs 0.09 episode/patient/year, p < 0.005), peritonitis (0.33 vs 0.10 episode/patient/year, p < 0.005), and catheter loss (0.12 vs 0.05, p < 0.01) were significantly higher among the carriers. Life-table analysis showed a significant risk of S. aureus exit-site infection and peritonitis for carriers (p < 0.01). Logistic regression analysis showed that S. aureus nasal carriage was the most important predictive factor for S. aureus peritonitis. In conclusion, our study showed that S. aureus nasal carriage is related to an increased incidence of S. aureus CAPD-related infections.

Psychosocial and psychiatric morbidity in patients on CAPD.

Continuous ambulatory peritoneal dialysis (CAPD) is an important mode of therapy for patients with end-stage renal disease. Although techniques and patient survival rates have improved, the psychosocial rehabilitation of Asian CAPD patients has not been studied. The aim of this study is to measure the extent of psychosocial and psychiatric morbidity in a sample of Asian CAPD patients. Patients from the outpatient CAPD facility affiliated with a tertiary care hospital were randomly selected and enrolled in the study. Demographic and clinical data were collected. Psychosocial and psychiatric assessments using the Hospital Anxiety and Depression Scale and coping style questionnaires were performed by a trained psychiatrist. The patients' most bother-some symptoms and specific worries were noted. Thirty of 105 stable CAPD patients (mean age 54.2 +/- 14.1 years, M:F 1:2, mean duration on CAPD 22.3 +/- 8.3 months) were studied. Twenty-one patients were married. Twenty-two patients were uneducated, 19 were unemployed, and 9 were homemakers. Based on the Hospital Anxiety and Depression scales, 50% of the patients were identified as cases of anxiety and 13% as depression. Although 93% of the patients accepted their illness, 46% of the patients were in a state of despair and hopelessness. Pruritus was the most frequent complaint (40%), followed by dietary restrictions (23%). The main worries were financial in 83% of patients, sexual dysfunction in 73%, and unemployment in 67%. In conclusion, Asian CAPD patients have a high degree of undetected psychosocial and psychiatric morbidity. These issues need to be addressed to provide adequate psychosocial rehabilitation.

A prospective randomized comparison of single versus multidose gentamicin in the treatment of CAPD peritonitis.

There is an increasing trend towards the use of aminoglycosides in a once-daily dose administration for the treatment of severe infections in nonrenal failure patients. The use of once-daily dose aminoglycoside therapy may be associated with a reduction in toxicity. We performed a prospective randomized study comparing once-daily versus multiple-dose gentamicin in the treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Seventy-three patients with 100 new episodes of peritonitis were enrolled in the study. At presentation of peritonitis, the patients were alternately assigned to receive either intraperitoneal gentamicin at a dose of 40 mg/2 L dialysate administered as a once-daily dose or gentamicin at a dose of 10mg/2 L dialysate administered 4 times per day. All patients also received intraperitoneal vancomycin at a dose of 1 g per week. There were no significant differences in the treatment success (88% vs 82%, p = NS) and relapse (18% vs 20%, p = NS) rates between the once-daily dose and multiple-dose groups. The mean trough serum gentamicin level was higher in the once-daily dose group compared to the multiple-dose group (0.75 +/- 0.72 vs 1.50 +/- 1.40 mg/L). In conclusion, gentamicin administered in a once-daily dose is as effective as multiple-dose administration in the treatment of CAPD peritonitis. The lower gentamicin level with once-daily dose administration may be associated with a reduction in aminoglycoside toxicity.

The use of semi-quantitative urine test-strip (Micral Test) for microalbuminuria screening in patients with diabetes mellitus.

BACKGROUND: Microalbuminuria is an early marker of prognostic significance in diabetic renal disease. However, testing for microalbuminuria in a timed sample of urine using the double antibody radioimmunoassay (RIA) method is cumbersome and requires special laboratory facilities. Recently, a test strip for microalbuminuria, the Micral Test was available and we evaluated the performance of this test strip as a screening method for detection of microalbuminuria. METHODS: One hundred consecutive diabetic patients who were tested to be dipstick-negative (Albustix) for proteinuria were enrolled for the study. Micral Tests were performed on a paired first morning and random urine specimen from the same patient and the results compared with a timed 24-hour urine measurement of urine albumin excretion using the RIA method. RESULTS: Eighteen specimens were tested positive by the RIA method with a urinary albumin range of 32-177 mg/24 hours. With the Micral Test, the following sensitivity, specificity, positive and negative predictive values were obtained: 66.7%. 97.6%, 85.7% and 93.0% for the first morning urine specimens, and 77.8%, 91.5%, 66.7% and 94.9% for the random urine specimens. CONCLUSIONS: These results suggest that Micral Test with either the first morning or random urine specimen offers a simple, reliable, rapid and convenient method for screening of microalbuminuria in the diabetic patient.

Dermal mast cell density and pruritus in end-stage renal failure.

Skin mast cell density was determined in two age- and sex-matched groups of patients with end-stage renal failure, one with severe uraemic pruritus (n = 9) and the other without (n = 9). In each group, seven patients were on chronic haemodialysis. In uraemic patients without pruritus, skin mast cell density was similar to that in eight healthy controls (40.1 +/- 10.2 mm2 versus 46.5 +/- 20.6 mm2; P = 0.44), a result also obtained when only the patients on haemodialysis were considered (39.3 +/- 14.7 versus 46.5 +/- 20.6; P = 0.46), showing that haemodialysis per se did not cause mast cell proliferation. In contrast, uraemic patients with itch had significantly higher dermal mast cell counts when compared with those without itch (71.8 +/- 36.4 mm2 versus 40.1 +/- 12.9 mm2; P = 0.01). However, there was no difference in serum parathyroid hormone (PTH) and calcium or phosphate concentrations between the two groups. In addition, there was no significant correlation between dermal mast cell density and serum PTH, calcium or phosphate concentrations. These data suggest that uraemic pruritus may be related to mast cell proliferation in the skin.

Bilateral vocal cord paralysis secondary to treatment of severe hypophosphatemia in a continuous ambulatory peritoneal dialysis patient.

Neuromuscular complications, including tetany and laryngeal spasm, are recognized complications of hypocalcemia and hypomagnesemia. We present a continuous ambulatory peritoneal dialysis patient with hypomagnesemia who developed hyperphosphatemia and profound hypocalcemia after oral phosphate replacement for severe hypophosphatemia. The combination of hypocalcemia and hypomagnesemia resulted in life-threatening bilateral vocal cord paralysis. Phosphate replacement should be determined and given cautiously, particularly in patients with renal failure and concomitant electrolyte disturbances.