An outbreak of Salmonella enteritis and septicemia in a population of uremic patients. A review of four cases, including infection of an arteriovenous fistula.

An outbreak of enteritis and septicemia caused by Salmonella enteritidis occurred in a population of uremic patients treated in a nephrology unit. In one of the patients, an arteriovenous fistula was infected by this organism. The source of the outbreak was traced to the refrigerator and sink in the unit. This degree of morbidity and mortality far exceeds that previously reported in infections with nontyphoid Salmonella sp and is presumbly related to the decreased immune response seen in uremia.

Relationship of plasma lipids to renal function and length of time on maintenance hemodialysis.

Significant hypertriglyceridemia, the most common lipid abnormality in renal failure, first occurs when the creatinine clearance falls to 50 ml/min. The prevalence of hypertriglyceridemia continues to rise as creatinine clearance falls further with the highest rate developing at a creatinine clearance less than 10 ml/min. Hypertriglyceridemia is correlated with plasma glucagon levels but not growth hormone or insulin. Plasma cholesterol values remain normal in the face of deteriorating renal function and show no correlation with any of the hormones measured. Although all three hormones became elevated as renal function diminished, none were directly correlated with glomerular filtration rate. There was a distinct decrease in the prevalence of hyperlipidemia after 5 years of maintenance hemodialysis therapy. Plasma growth hormone and glucagon through an effect on plasma triglyceride and plasma insulin by effecting plasma cholesterol may play a role in this decline of hyperlipidemia with duration of hemodialysis.

Similarities between glomerular sclerosis and atherosclerosis in human renal biopsy specimens: a role for lipoprotein glomerulopathy.

Much recent work has focused on the progressive nature of renal injury, and hemodynamic alterations have been implicated in the pathogenesis of the predominant lesion, focal glomerulosclerosis. Despite the well-documented atherogenic toxicity of lipids in cardiovascular morbidity, little is known about lipid-associated renal injury. However, lipids are toxic to endothelium, and the glomerulus is a vascular bundle. Several authors participating in this symposium have presented evidence for an association between hyperlipidemia and glomerulosclerosis in animal models. This association is particularly significant given the expanded therapeutic armamentarium now available to treat hyperlipidemia. In fact, glomerular injury may be moderated by pharmacologic treatment of hyperlipidemia in a rat renal ablation model. Very little evidence exists, however, for a similar association in human renal disease. We have, in the course of clinical practice, made certain observations in renal biopsy specimens that may for the first time link atherogenesis and lipid deposition to human glomerular injury.

Cholesterol and lipid disturbances in renal disease: the natural history of uremic dyslipidemia and the impact of hemodialysis and continuous ambulatory peritoneal dialysis.

Lipid abnormalities have been postulated to contribute to renal insufficiency by a mechanism that is analogous to atherogenesis. The majority of patients treated for chronic renal failure die of cardiovascular complications. Lipid abnormalities in this group are thought to contribute to this high mortality. Proving a causal association between dyslipidemia and accelerated atherosclerosis in the end-stage renal disease population has been confounded by the presence of other pro-atherogenic conditions in this population. The current study compiles the lipid data we have accumulated from our renal population for the years 1987 to 1989. The report is divided into three main parts: The first is a survey of lipid levels and atherogenicity indicators in groups with different types of renal disease or modalities of treatment. The second is a multivariate analysis of the relationship of clinical and biochemical variables (and their interactions) to the serum lipid and apolipoprotein levels and their ratios and their change over time in a large dialysis population. In the third study, we quantitate the peritoneal clearances of apolipoproteins A-I and B in patients undergoing continuous ambulatory peritoneal dialysis and assess the relationship of these clearances to serum lipid and lipoprotein levels and risk ratios.

Importance of low serum intact parathyroid hormone as a predictor of mortality in hemodialysis and peritoneal dialysis patients: 14 years of prospective observation.

Excess parathyroid hormone (PTH) has long been considered detrimental to the health of patients with end-stage renal disease. PTH has been implicated as a multisystem uremic toxin, and hyperparathyroidism can be a debilitating complication in dialyzed patients. We have studied prospectively the relationship of enrollment serum intact PTH and various demographic characteristics and other biochemical parameters to all-cause mortality in 345 hemodialysis (HD) and 277 peritoneal dialysis (PD) patients. We monitored the patients for 14 years. Observed survival and survival after adjustment for age, race, gender, months on dialysis at enrollment, diabetic status, and nutritional markers were significantly better for patients with enrollment PTH greater than 200 pg/mL than for patients with PTH 65 to 199 pg/mL and patients with PTH less than 65 pg/mL. Enrollment serum PTH was an independent predictor of survival in HD and PD patients. For HD patients, age and months on HD at enrollment were associated inversely with PTH level, whereas black race, creatinine, and phosphorus were associated directly with PTH. For PD patients, age, diabetes, and months on PD at enrollment were inverse predictors, whereas black race, albumin, creatinine, and phosphorus were associated positively with PTH. Lower than expected levels of PTH in uremic patients is associated with increased mortality. We hypothesize that inadequate protein intake or phosphorus intake or both result in impaired development of the expected secondary hyperparathyroidism and in the excess mortality risk inherent with malnutrition.

Serum prealbumin predicts survival in hemodialysis and peritoneal dialysis: 10 years of prospective observation.

Malnutrition is a major factor contributing to the high mortality rate in hemodialysis (HD) and peritoneal dialysis (PD) patients. We and others have reported previously that single enrollment levels of serum biochemical markers, such as albumin, cholesterol, creatinine, and prealbumin, are correlated directly with mortality in HD and PD patients. We have studied prospectively the relationship of enrollment prealbumin levels, demographic characteristics, and other biochemical markers to all causes of mortality in 130 HD and 128 PD patients who were monitored for 10 years. The Kaplan-Meier method was used to compute observed survival, and the Cox proportional hazards model was used to identify independent predictors of mortality risk. For HD patients, enrollment serum prealbumin remained a strong independent predictor of long-term survival after adjusting for age, race, gender, months on dialysis, diabetic status, and other nutritional markers. In PD and HD patients, observed and adjusted survivals (after adjusting for aforementioned confounding variables) of patients with prealbumin greater than 30 mg/dL were significantly higher than survivals of patients with prealbumin less than 30 mg/dL. For HD and PD patients, age and diabetes were associated inversely with prealbumin concentration, whereas levels of albumin, creatinine, and total cholesterol were associated directly with prealbumin concentration. In this study, prealbumin was the best biochemical predictor of mortality for HD patients and a useful tool to assess nutritional risk in HD and PD patients.

Survival on hemodialysis and peritoneal dialysis over 12 years with emphasis on nutritional parameters.

We analyzed the prognostic importance of nutritional markers and mortality data in 537 hemodialysis (HD) and 422 peritoneal dialysis (PD) patients followed for up to 12 years. Patients on HD had a 44% lower risk of mortality than did those treated with PD (P: < 0.0001). The difference in mortality between the modalities was even more striking among diabetics but less striking among younger patients. Over a 12-year period, survival of dialysis patients with lower enrollment levels of albumin, creatinine, and parathyroid hormone (PTH) were significantly lower. In multivariate Cox's proportional hazards models, serum prealbumin and enrollment PTH level of <65 pg/mL were independent predictors of mortality both in HD and PD patients. In conclusion, HD patients had higher cumulative survival than PD patients over a 12-year period. Nutritional markers at enrollment continue to be strong predictors of mortality for up to 12 years.

Dyslipidemia in renal disease.

In summary, dyslipidemia is a common feature of various renal syndromes. Whether this perturbed lipid metabolism results in accelerated atherosclerosis and increased cerebrovascular and cardiovascular morbidity and mortality remains a subject of inquiry. Also undefined is the role of dyslipidemia in the progression of renal injury. The malnutrition that becomes a dominant morbid feature in patients on maintenance renal replacement therapy provides a caveat against aggressive intervention for modest hyperlipidemia once dialysis is instituted. Individualized assessment of end organ atherosclerotic disease and cardiovascular risk factors should form the basis for modification of the treatment plan (ie, pharmacological intervention) should nonpharmacological means prove ineffective.

Survival in uremia due to systemic diseases.

A retrospective analysis of the mortality and morbidity experience with maintenance hemodialysis as treatment for uremia in systemic disease was conducted. Between 1962 and 1977, a total of 141 patients with chronic glomerulonephritis and 120 patients with uremia caused by renal involvement in systemic disease were treated. With the exception of two patients with bacterial endocarditis who died early in their course, survival in the diagnostic categories studied ranged from acceptable, in diabetics with 29 of 53 (54.7%) patients living, to excellent in tuberculosis where all of six patients are alive and well. Overall, it is concluded that uremia in systemic disease is responsive to maintenace hemodialysis.

The natural history of diabetic nephropathy: unpredictable insulin requirements--a further clue.

Diabetic nephropathy has evolved into the single most prevalent cause of uremia among patients sustained by the United States End Stage Renal Disease program. Clarification of the natural history of kidney involvement and insufficiency in Type I and II diabetes has improved substantially over the past 5 years. However, it remains a poorly understood and relatively underreported morbid entity. This report reviews the problem, then reconstructs the natural history of diabetic nephropathy by studying the course of 50 Type I and Type II uremic diabetics treated with hemodialysis at The Long Island College Hospital. It traces the various stages from hyperglycemia to proteinuria to renal failure, and then reports morbidity, including cardiac, eye, stroke, and amputation complications. A new paradox is herein reported--the unpredictable insulin requirement, including new insulin need for the first time once hemodialysis was begun, in 8 of 50 patients studied.

Predictors of survival in continuous ambulatory peritoneal dialysis patients: a five-year prospective study.

Our objective was to examine the influence of various demographic, clinical, and enrollment biochemical variables on the long-term survival of continuous ambulatory peritoneal dialysis (CAPD) patients. This was a prospective cohort study investigating the relationship between demographics and enrollment biochemical markers and mortality in CAPD patients in a CAPD unit in a large tertiary care teaching hospital. One hundred and sixty-nine patients in the CAPD program were enrolled between 1989 and 1994, and were followed up to 60 months. Independent predictors of mortality determined by Cox proportional hazards model included age, diabetes, serum albumin and creatinine. Enrollment level of serum albumin, and creatine can predict mortality in CAPD patients up to 60 months. Markers of visceral and somatic nutrition at enrollment are important predictors of mortality in CAPD patients up to five years.

Anemia severity and missed dialysis treatments in erythropoietin-treated hemodialysis patients.

Neither the sociodemographic correlates nor the biochemical/clinical consequences of missed dialysis treatments have been well defined. During a 10 week period, the authors enumerated missed dialysis treatments among 430 patients randomly selected from a pool of 1,395 hemodialysis patients. A forward logistic regression model was used to determine whether a relationship existed between missed dialysis treatments and the following independent variables: age, gender, race, renal diagnosis, length of time on maintenance hemodialysis, co-morbidity index, modified Karnofsky score, employment status, household residents, and laboratory indices. Forty-three (10%) of 430 patients missed a total of 96 treatments. Despite equivalent treatment with erythropoietin, patients who missed dialysis treatment(s) had a lower mean hematocrit (27 +/- 4.3%) at the end of the study than those patients who underwent all treatments (29 +/- 4.5%) (p = 0.0287). Mean serum albumin and creatinine levels were equivalent in compliant and noncompliant patients. Recent starts (p = 0.0048), and younger patients (p = 0.0424) were most likely to miss dialysis treatment(s). One of the major consequences of missed dialysis treatment(s) is exacerbation of anemia, and younger patients and freshly started patients are more likely to miss scheduled dialysis treatments than their respective counterparts.

Successful treatment of tuberculous peritonitis while maintaining patient on CAPD.

Although conventional wisdom advises removal of the Tenckhoff catheter as part of the therapy for tuberculous peritonitis, there are a few recent reports of cases successfully treated while maintaining the patients on CAPD. We wish to report three cases treated without interrupting CAPD. In two of the patients, cultures were positive for Mycobacterium tuberculosis and in the third case, although the cultures were negative, the patient improved on anti-Tb medications. Smear for AFB was positive in one patient; and two had a positive PPD. All had predominance of lymphocytes and monocytes in effluent. The total WBC count was 160-300 and two patients had fever. All had abdominal pain. One patient was treated with INH and ethambutol; one with INH and rifampin and one (who was suspected of being HIV+) also received pyrazinamide (PZA) until culture was available. Cultures grew in 4-6 weeks. All were started on therapy prior to having the culture results, and all showed clinical improvement within two weeks. One patient had his catheter replaced two months later because of pseudomonas peritonitis, continued on CAPD for an additional five months, then changed to HD because of recurrent bacterial peritonitis. One patient died of complications of diabetic vascular disease three months later with no evidence of peritonitis. One patient has remained on anti-Tb treatment for seven months and is doing well on CAPD.

Variability of peritoneal clearances for apolipoprotein and its relationship to susceptibility for atherosclerotic changes in CAPD.

Apolipoprotein Clearance and Atherogenicity in CAPD: Protein and lipoprotein loss is one of the disadvantages of CAPD. The impact of these losses on serum constituents is not fully understood. Lipoprotein disorders are observed in patients with chronic or acute renal failure or undergoing dialytic therapy with resultant increase in atherosclerotic clinical events yet these phenomenon are poorly understood, underinvestigated and underreported. Thus the impact of dietary and pharmacological steps to prevent these events are limited by lack of clinical facts. The recent emergence of effective lipid lowering agents makes a rapid analysis of parameters important. We studied the relationships between peritoneal clearance of apolipoproteins and serum atherogenicity indicators in a preliminary study of 10 CAPD patients with and without peritonitis. We measured total cholesterol (TC), HDL-Cholesterol (HDL-C), Apo A-I and Apo B and dialysate levels of Apo A-I and Apo B. Apo levels were determined immunotubidimetrically, and dialysate was concentrated by ultrafiltration. A subsequent prospective group of 10 additional patients was studied to test the relationship found in the preliminary study. In both preliminary and prospective nonperitonitis groups, the ratio of peritoneal clearance of Apo A-I to Apo B correlated strongly with the serum TC/HDL-C (r = 0.9 preliminary, r = 0.78 prospective group). There was an inverse correlation between the clearance ratio and both serum HDL-C (r = -0.71 preliminary, r = -0.77 prospective group) and serum Apo A-I/Apo B (r = -0.74 preliminary, r = -0.62 prospective group).(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Is an elevated level of serum lipoprotein (a) a risk factor for cardiovascular disease in CAPD patients?

Cardiovascular disease (CVD) is the single most important cause of mortality in hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) patients. An increased lipoprotein (a) [Lp(a)] level in HD patients is associated with CVD. However, Lp(a) levels in CAPD patients are controversial, and their association with CVD has not been established. In the present study, prevalent CAPD and HD patients [excluding those who were human immunodeficiency virus (HIV)-positive] attending the Long Island College Hospital from June, 1990 to July, 1995 underwent analysis of lipid profile including Lp(a). Total and low-density lipoprotein cholesterol, triglycerides, apolipoprotein (apo) A, and apo B were all significantly increased in CAPD patients compared to HD patients. Serum Lp(a) levels were also significantly higher in CAPD patients than in HD patients (51 +/- 32 vs 34 +/- 23 mg/dL, p < 0.001). CAPD patients who had a history of myocardial infarction (MI) or coronary artery disease (CAD) at enrollment had significantly higher Lp(a) levels compared to those who did not have a history of MI or CAD. CAPD patients who died of CVD had higher Lp(a) levels than patients who died of non-CVD causes. In the Cox model with backward stepwise selection, a history of CVD was associated with a significantly elevated relative risk (RR) of mortality (RR = 1.84, p = 0.014). Expected survival by all causes of mortality and by cardiac mortality was significantly shorter in patients with a history of CVD than in those without a history of CVD. Thus, elevated Lp(a) is related to increased CVD and therefore may contribute to increased mortality in CAPD patients.

The impact of CAPD treatment on lipid metabolism and cardiovascular risk.

The metabolism of lipids in CAPD has not been fully elucidated. To further clarify the behavior of dyslipidemia in this setting we followed the values of total cholesterol (TC), HDL-cholesterol (HDL-C) and apolipoprotein (apo) parameters over time (12-24 months) in 40 patients and correlated these values and their ratios with clinical (age, gender, race, weight, diabetes, etc.) and biochemical (multiphastic screen) information. Mean HDL-C was lower in men (p less than 0.04), in whites, (p less than 0.03) and in diabetic patients (p less than 0.05), but there were no group differences for mean total cholesterol, mean apolipoprotein values, the atherogenic risk ratio TC/HDL-C, or the anti-atherogenic ratio apo A-I/apo B. Total months on CAPD was found to correlate positively with TC/HDL-C (p less than 0.05), an atherogenic risk factor, and to correlate negatively with HDL-C (p less than 0.02), an anti-atherogenic index. There was also a negative correlation with another anti-atherogenic index, apo A-I/apo B, which did not reach statistical significance (r = -0.41, p = NS). Counterbalancing this apparently increased atherogenic risk is the stability of individual parameters for each patient over time in this study. In fact, the good news appears to be that TC, HDL-C, apolipoproteins and the risk ratios TC/HDL-C and apo A-I/apo B all remained stable over 12-24 months (p = NS by paired t-test for all). Thus, we find no evidence for worsening of the uremic dyslipidemia over time with CAPD treatment.

Outcome of percutaneous endoscopic gastrostomy feeding in patients on peritoneal dialysis.

Protein malnutrition is now well established as an important contributory factor to the high mortality in peritoneal dialysis (PD) patients. Low dietary protein calorie intake is one of the factors leading to protein malnutrition. If PD patients develop difficulty eating, percutaneous endoscopic gastrostomy (PEG) feeding may prove beneficial in providing adequate nutrition. Studies on the effectiveness of PEG feeding in PD patients are limited to pediatric patients. The objective of the present study was to assess the outcome of PEG feeding in adult patients with end-stage renal disease (ESRD) on PD. We retrospectively reviewed charts from May 1992 to February 2000 of 10 consecutive patients in our center who had had feeding tubes inserted. The patients' ages ranged from 37 to 81 years, with mean age of 65. Of the 10 patients, 7 were male, 5 were diabetic, and 1 was infected with the human immunodeficiency virus. Two patients had cerebrovascular accident (CVA) with dysphagia, 3 had multi-infarct dementia, 2 had anoxic encephalopathy, 2 had dementia, and 1 had calciphylaxis with anorexia. Of the 10 patients, 9 failed to eat because of neurologic disorders. Two patients who had functioning PEG feedings before starting PD had no complications. Only 2 of 8 patients already on PD continued with long-term PD after a PEG was inserted. Both patients whose PD was not interrupted at the time of PEG placement immediately developed peritonitis. Of the 6 patients who were maintained on hemodialysis (HD), 2 developed peritonitis within one week of starting PEG feedings. The other 4 had no complications from PEG feedings while being maintained on HD, but 1 developed peritonitis when PD was resumed. Of the 5 patients who developed peritonitis, 3 experienced fungal peritonitis. In PD patients, PEG feeding is associated with frequent complications. However, PEG placement prior to PD initiation appears to be safe. Maintaining patients on HD for at least 6 weeks appears to decrease the incidence of peritonitis, but does not eliminate it. Use of anti-fungal prophylaxis and maintenance of the patient on HD for longer than 6 weeks may produce better results.