[Correlates of potassium transport during peritoneal equilibration tests using different dialysate glucose concentrations]. / Análisis del transporte peritoneal de potasio mediante pruebas de equilibrio peritoneal con diferentes concentraciones de glucosa.

BACKGROUND: there are gaps in the knowledge of factors which influence peritoneal potassium transport in Peritoneal Dialysis (PD). The aims of this study were to compare peritoneal potassium transport in PD patients undergoing 2.27% and 3.86% peritoneal equilibration tests (PET), and to disclose clinical correlates of this phenomenon. METHOD: ninety PD patients underwent 2.27% and 3.86% PET, in a random order. We compared peritoneal potassium transport in both tests, and searched for correlations between D/P potassium at 240 minutes (main study variable) and PET-derived markers of peritoneal function and selected demographic, clinical and biochemical variables, using a multivariate approach. MAIN RESULTS: D/P potassium showed a good agreement between both PET, and presented a univariate association with creatinine transport, but not with plasma potassium, ultrafiltration or sodium dip. Age, PD modality, peritoneal glucose load, icodextrin, ACEI-ARA and calcium antagonist therapy, urinary potassium and glomerular filtration rate were other univariate correlates of potassium transport. Multivariate analysis confirmed D/P creatinine at 240 minutes (B=0.40 [95% CI 0.26-0.53] 2.27%, B=0.36 [0.21-0.51] 3.86%, p < 0.0005) as the main predictor of D/P potassium at 240 minutes. Urinary potassium, rather than glomerular filtration rate, sustained also an inverse correlation with the dependent variable. Treatment with ACEI-ARA was consistently associated with peritoneal potassium transport (3.86% PET B=0.08 [0.04-0.12], p < 0.0005). CONCLUSIONS: The 2.27% and the 3.86% PET show a good agreement at the time of estimating peritoneal potassium transport. Urinary potassium excretion and treatment with ACEI-ARA (3.86% test) show an independent association with peritoneal potassium transport rates.

[Inflammation, residual renal function, overhydration, and membrane failure. The Rubik's cube of peritoneal dialysis]. / Inflamación, función renal residual, sobrehidratación y fallo de membrana. El cubo de Rubik de la diálisis peritoneal.

Over the last years, a large amount of experimental and clinical evidence has been accumulated that supports the existence of interactions between the decline in residual renal function, hydration status, inflammatory states and functional and structural deterioration of the peritoneal membrane in patients treated with peritoneal dialysis. These interactions are complex and remain far from being fully understood, but each one of these alterations appears to be capable of aggravating the harmful effects of the others, clearly affecting the probabilities of survival of these patients. Preservation of residual renal function and functional capacity of the peritoneal membrane, together with other measures to prevent overhydration and reduce the intensity of inflammatory phenomena, are essential mechanisms for risk prevention in these patients, and should be addressed from a joint perspective. New peritoneal dialysis solutions, apparently more biocompatible, could play an essential role in the achievement of these objectives.

[Immunosuppressive treatment in patients starting peritoneal dialysis after functional arrest of kidney transplant. What to do?]. / Tratamiento inmunosupresor en el paciente que inicia diálisis peritoneal tras el cese funcional del trasplante renal. ¿Qué hacer?

The growing number of kidney patients who have to restart dialysis after functional failure of a kidney transplant has brought to this context the general controversy on dialysis modality selection criteria. These should be applied from a longterm perspective, since each patient may benefit more from one treatment or another at different times in his clinical course. When the issue is analyzed from a general perspective, peritoneal dialysis and hemodialysis seem to provide similar results in renal transplant patients, although the available information is still insufficient. The crucial prognostic nature of residual renal function in incident patients on peritoneal dialysis brings up the issue of wether it is appropriate to maintain some type of immunosuppression after restarting dialysis, at least until total failure of graft function. This decision is currently based on purely empirical considerations, since we do not have reliable information to answer the key questions. Thus, we do not know if residual renal function has the same importance in this context as in the overall renal population. Neither if withdrawal of maintenance of immunosuppression will presumably have the same effect in all cases. The side effects of maintaining partial immunosuppression and the overall clinical yield for the patient are also not well defined. Finally, it is unclear what immunosuppression should be maintained, although there is agreement that it should be lowgrade; steroids and to lesser extent calcineurin inhibitors are the preferred agents, but always on empirical grounds. Because of the growing importance of this subpopulation of renal patients, these questions should be answered in a systematic manager in coming years.

[Economic study of dialysis using the cost-per-procedure method according to clinical protocols]. / Estudio económico de la diálisis por el método de coste por procedimiento ajustado a protocolo clínico.

Studies analyzing the economic cost of dialysis therapy have raised a considerable interest in the nephrologic community, both inside and outside our country. The objective of the present study was to approach this question from a different point of view, by applying the cost-per-procedure method, according to clinical protocol, to all the routine clinical procedures in our dialysis unit (both Hemodialysis and Peritoneal Dialysis). We analyzed 68 routine protocols (42 for Hemodialysis and 26 for peritoneal Dialysis), carrying out a pormenorized study of all the components of the economic cost of each procedure (personnel, laboratory, surgical and sanitary material, drugs and other concepts). We calculated the final cost of all these procedures after individualizing the different components of the economic spends, with the informatic support of the management department of our center, and in coordination with the data bases of the Pharmacy and General Supplies units. Although the initial implementation of this method is tedious, it subsequently allows to analyze the global cost of therapy in the Unit, as also the cost of certain subsets, or even particular patients, in a simple and flexible way. Moreover, the system is easy to update, as clinical protocols undergo changes or the economic cost of individual components vary. Finally, this method is a useful tool at the time of comparing the cost of clinical procedures in different centres, according to their varying clinical protocols, economic spends and clinical results.

Agreement between two routine methods of estimation of glomerular filtration rate in patients with advanced and terminal chronic renal failure.

BACKGROUND: Estimations of glomerular filtration rate (GFR) obtained either by the modification of diet in renal disease study equation (MDRD-GFR) or by classic 24-hour urine collection-based methods (mean of creatinine and urea clearance (Ccr-ur)) are considered to be equivalent in patients with chronic renal failure (CRF). However, the agreement between both methods has been insufficiently studied in patients during the most advanced stages of CRF. METHODS: We compared 615 estimations of GFR performed by both methods simultaneously in adult (> 18 years) patients with advanced (aCRF) (15 - 30 ml/min/1.73m2) and preterminal (tCRF) (< 15 ml/min/1.73m2) chronic renal failure. We also analyzed the influence of some relevant covariables (demographic characteristics, inflammatory and nutritional markers) with respect to the concordance between both methods. RESULTS: In aCRF, mean GFR were 19.7 +/- 5.5 (MDRD-GFR) and 19.3 +/- 3.7 ml/min/1.73m2 (Ccr-ur) (mean difference 0.4 ml/min/1.73m2, 95% confidence interval CI -0.3/1.1, p = 0.26), with an intraclass correlation coefficient of 0.46. In tCRF, mean GFR was 12.5 +/- 4.2 and 10.4 +/- 2.7 ml/min/1.73m2, respectively (mean difference 2.1 ml/min/1.73m2, 95% CI 1.7/2.4, p < 0.0005), with an intraclass correlation co-efficient of 0.43. Multivariate analysis identified lean body mass, body mass index, protein nitrogen appearance, proteinuria, gender, age, albumin (aCRF) and prealbumin (tCRF) as variables independently correlated with the difference MDRD-GFR minus Ccr-ur. Lean body mass was by far the strongest predictor of deviations between both methods, both in aCRF (R2 = 0.66, p < 0.0005) and tCRF (R2 = 0.49, p < 0.0005). CONCLUSIONS: MDRD-GFR and Ccr-ur show an acceptable agreement in advanced stages of chronic renal failure. However, MDRD-GFR produces estimations of GFR systematically higher than those given by the Ccr-ur method, in patients with tCRF. Moreover, this overestimation is particularly marked in some high risk subsets, including elderly patients and those presenting markers of a poor nutritional condition. Until this issue is further clarified, GFR should be estimated using Ccr-ur rather than MDRD-GFR in patients with tCRF, as also in older and malnourished patients with aCRF, as this may represent a more conservative and safer approach at the time of planning initiation of renal replacement therapy.

Early proteinuria in renal transplant recipients treated with cyclosporin.

PURPOSE: To establish the risk profile for the development of proteinuria in the first months after renal transplantation and to disclose the prognostic significance of this finding. DESIGN: We conducted an observational historic cohort study. SETTING: We conducted the study in a tertiary care hospital renal transplantation unit covering a potential population of approximately 2 million. We made extensive use of suboptimal donors. POPULATION: In our unit, 560 cadaveric renal transplants were performed between January 1988 and June 1997, under Cyclosporine immunosuppression, with a minimum follow up of 1 year. METHOD: The risk profile analysis explored early clinical factors reported to be related to the late course of renal transplantation. The study of the prognostic significance of proteinuria included survival analysis and correlation with late markers of graft dysfunction, taking into consideration the intensity and persistence of early proteinuria. A multivariate approach was used in all cases. RESULTS: Early proteinuria was strongly associated with delayed graft function (odds ratio [OR] 1.03/day of dialysis), acute rejection (OR 1.7 for steroid-sensitive and 6.2 for steroid-resistant rejection), renal transplant to a hypersensitized recipient (OR 2.5), and pediatric (<5 years)(OR 4.1) or older (>60 years)(OR 3.0) donors. The predictive model for persistency of proteinuria was very similar, whereas transient proteinuria could not be adequately modeled. Increasing intensity of proteinuria was strongly associated with poor patient and graft survival. Persistent, but not transient, proteinuria supported this relationship. CONCLUSIONS: Proteinuria appearing early after renal transplantation is strongly associated with delayed graft function, acute rejection, and the use of pediatric or older donors. Whatever its background, proteinuria is a strong predictor of poor patient and graft survival. This effect is directly related to the intensity and persistence of the disorder.

Early immunologic and nonimmunologic predictors of arterial hypertension after renal transplantation.

We followed up a cohort of 680 renal transplant recipients receiving cyclosporine (CsA) immunosuppression with the aim of establishing an early-risk profile for early and late hypertension (HT) after renal transplantation (RTx), specifically comparing the predictive role of immunologic and nonimmunologic markers of graft prognosis. HT was defined as the need for antihypertensive drugs. The prevalence of HT was 65% at the time of RTx, increased to a peak of 78% at the end of the first year, and stabilized between 71% and 73% thereafter. Multivariate analysis identified HT at the time of RTx, basal renal disease, and grafting the right kidney as independent predictors of HT 3 months after RTx. The risk profile for HT 12 months after RTx included HT present at RTx, grafting the right kidney, markers of early ischemia-reperfusion injury (delayed graft function, cold and warm ischemia), and transplant from an elderly or female donor. Polytransfusion before RTx was associated with a decreased risk for HT, but retransplantation, increased reactivity against the lymphocyte panel, poor HLA compatibility, and early acute rejection did not portend an increased risk for the complication under study. The CsA schedule (dose, trough levels) correlated poorly with the blood pressure status of the patients, but simultaneous graft function was independently associated with late HT. In conclusion, the early predictive profile for HT after RTx includes, preferentially, nonimmunologic markers of graft prognosis. Hyperfiltration damage may be a significant pathogenic mechanism for this complication of RTx.

The prognostic significance of acute renal failure after renal transplantation in patients treated with cyclosporin.

We studied 733 cadaveric renal transplant patients (747 transplants) under cyclosporin immunosuppression, to: (i) establish the risk profile for acute renal failure (ARF) after renal transplantation in a unit using many sub-optimal donors; (ii) assess the long-term prognostic relevance of ARF; and (iii) explore the synergistic prognostic significance of delayed graft function and acute rejection during the early post-transplant period. Transplanting from a non-heart-beating or elderly donor, protracted cold ischaemia, haemodialysis immediately before transplant surgery, poor HLA matching, and grafting to a hypersensitized recipient without residual renal function, all independently predicted delayed graft function. This delay had no detrimental effect on patient or graft survival, but prolonged ARF was associated with increased mortality from infection. Late markers of graft dysfunction (poor graft function, proteinuria, hypertension) were highly prevalent among grafts affected by ARF, specially in prolonged ARF. Delayed graft function and early acute rejection showed a definite, albeit not strong, additive impact on late graft survival, and also on the prevalence of late markers of graft dysfunction.

Effects of two simplified methods of dialysate sampling on estimations of adequacy indices in automated peritoneal dialysis.

OBJECTIVE: To assess the effects of two simplified methods of dialysate sampling on the estimation of adequacy markers in automated peritoneal dialysis (APD). DESIGN: Cross-sectional noninterventional study. SETTING: Tertiary-care hospital. PATIENTS: Forty-nine patients undergoing standard APD therapy (36 nontidal, 13 tidal with low reserve volume). INTERVENTION: We estimated creatinine clearance (CCr), Kt/V urea, sodium removal, and peritoneal protein loss using two simplified methods. We calculated separate diurnal and nocturnal adequacies. Nocturnal concentrations of urea, creatinine, sodium, and proteins were extrapolated from dialysate samples taken after the first (method A) or the last (method B) cycle of the night. For the reference method, we estimated adequacy from a complete 24-hour dialysate collection. RESULTS: Spearman correlations versus the reference method were, for CCr, 0.82 for method A and 0.87 for method B; and for Kt/V, 0.78 (A) and 0.72 (B). Method A overestimated CCr by 19.6% (4.5 L/week)(median values) and Kt/V by 8.8% (0.12). Method B overestimated CCr by 5.0% (1.7 L/week) and Kt/V by 4.4% (0.06). Both methods estimated sodium removal accurately, but estimated protein loss poorly. Tidal APD was associated with a clear overestimation of adequacy indices with both methods. In fact, when only nontidal patients were considered, method B slightly underestimated CCr and Kt/V. CONCLUSIONS: In APD, estimation of nocturnal adequacy from dialysate samples taken after the first cycle is inaccurate. Estimation from samples taken after the last cycle yields suboptimal but acceptable results; the deviation is small and the dose of dialysis delivered to the patients is not overestimated.

Renal transplantation in patients undergoing chronic peritoneal dialysis.

OBJECTIVE: To review the outcome of renal transplantation in a group of patients treated with chronic peritoneal dialysis and to compare the results with those of a matched population on hemodialysis. DESIGN: Retrospective study. SETTING: Tertiary, institutional hospital, administering to a population of two million, with 100 patients on peritoneal dialysis. Six hundred and sixty renal transplantations were performed by the end of 1993. PATIENTS: Fifty-six patients on chronic peritoneal dialysis who received 58 cadaveric renal allografts were compared to 58 patients on hemodialysis who received a graft from the same donor (n = 39), or the transplant next to the one performed to the corresponding patient on peritoneal dialysis (n = 19). RESULTS: Patients on peritoneal dialysis showed a lower rate of delayed graft function (24.1 vs 50%, p < 0.05) and a similar incidence of acute rejection than patients on hemodialysis. Also, peritoneal dialysis patients received less supplementary immunosuppression, suffered a lower incidence of late infections (0.93 vs 0.58 episodes/patient), and had a similar incidence of dialysis-related complications (0.25 vs 0.20 episodes/patient). CONCLUSIONS: Patients on peritoneal dialysis do well after renal transplantation. The incidence of some complications, particularly delayed graft function, is lower than in patients on hemodialysis, while the incidence of dialysis-associated complications is similar in both groups.

Peritoneal dialysis is not a risk factor for primary vascular graft thrombosis after renal transplantation.

OBJECTIVE: To find out if patients undergoing peritoneal dialysis (PD) have an increased risk of primary vascular thrombosis of the renal allograft, compared with patients on hemodialysis (HD). DESIGN: Observational, retrospective cohort study. SETTING: Tertiary care hospital, covering an approximate population of 2,000,000. Extensive use of suboptimal donors for renal transplantation. PATIENTS AND METHODS: The study included 827 patients receiving a cadaveric renal transplantation (RTx) in our center between 1988 and 1997 (700 on HD and 127 on PD). We searched for a potential difference in the incidence of graft thrombosis, according to the pretransplant dialysis modality and taking into consideration the main reported risk factors for this complication of RTx. RESULTS: The accumulated incidence of primary graft thrombosis was 4.7% in PD patients, and 6.1% in HD patients (NS). Arterial and venous thrombosis were also similar in both groups. Logistic regression analysis demonstrated that extremes of age of the donor, use of the right kidney, protracted cold ischemia, delayed graft function, and transplantation to a hypersensitized recipient independently predicted graft thrombosis. Peritoneal dialysis was not independently associated with the complication under study (adjusted odds ratio HD/PD = 2.5, 95% CI = 0.8-7.7). CONCLUSIONS: Peritoneal dialysis is not associated with an increased risk of primary vascular thrombosis of the renal allograft.

A comparative analysis on the incidence of peritonitis and exit-site infection in CAPD and automated peritoneal dialysis.

OBJECTIVE: To compare the incidence of peritonitis and exit-site infection in an ample group of patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis in a single center during a 10-year period. DESIGN: Nonrandomized, prospective study. SETTING: Public, tertiary care hospital providing peritoneal dialysis care to a population of (approximately) 750 000 people. PATIENTS: We studied 213 patients on CAPD and 115 on automated peritoneal dialysis (APD) starting therapy between January 1989 and August 1998, with a minimum follow-up of 3 months. MAIN OUTCOME MEASURES: Using a multivariate approach, we compared the incidence, clinical course, and outcome of peritonitis and exit-site infections in both groups, controlling for other risk factors for the complications studied. RESULTS: The incidence of peritonitis was higher in CAPD than in APD (adjusted difference 0.20 episodes/ patient/year, 95% confidence interval 0.08 - 0.32). There was a trend for CAPD patients to present earlier with peritonitis than APD patients, yet the incidence of and survival to the first exit-site infection were similar in both groups. The etiologic spectrum of infections displayed minor differences between groups. Automated PD patients were more frequently hospitalized for peritonitis, but otherwise, the complications and outcome of peritonitis and exit-site infections did not differ significantly between patients on CAPD and those on APD. CONCLUSIONS: Automated PD is associated with a lower incidence of peritonitis than is CAPD, while exit-site infection is similarly incident under both modes of therapy. The etiologic spectrum, complications, and outcome of peritonitis and exit-site infection do not differ markedly between CAPD and APD. Prevention of peritonitis should be included among the generic advantages of APD over CAPD.

Effect of oral calcidiol treatment on its serum levels and peritoneal losses.

OBJECTIVES: To evaluate calcidiol serum levels in a group of continuous ambulatory peritoneal dialysis (CAPD) patients and the effect of oral calcidiol treatment on serum levels and peritoneal losses. STUDY DESIGN: Twenty patients (13 female, 7 male) were studied for 12-60 months. Their ages ranged 22-72 years (mean 46 +/- 15). Serum calcidiol, total protein and urea were determined at baseline and after the administration per os of 0.133 mcg/day of calcidiol for 10 days. At the same time, calcidiol and total protein were measured in peritoneal effluent at baseline and at 5, 10, and 40 days after starting this treatment. RESULTS: A significant and direct correlation between the calcidiol dialysis/plasma ratio and the peritoneal protein losses was found, both before and 40 days after calcidiol administration when calcidiol serum levels were the lowest. As calcidiol serum levels rose to the normal range in the course of the study, peritoneal losses of this metabolite increased slightly and correlated with calcidiol serum levels and urea mass transfer coefficient (MTC); the significant correlation between calcidiol serum levels and peritoneal protein losses disappeared. CONCLUSIONS: When serum calcidiol levels are low, calcidiol peritoneal losses in patients on CAPD correlate with protein peritoneal losses. However, when serum calcidiol levels rise, the calcidiol peritoneal losses correlate with calcidiol serum levels and urea MTC, and not with protein peritoneal losses.

Survival on chronic peritoneal dialysis: have results improved in the 1990s?

One hundred and seventy patients were treated with home peritoneal dialysis (PD) in our unit between 1986 and 1994. During this time lapse, several technical improvements were included in our practice. Among others there were: Swan neck permanent catheters, Y-systems, and automated home PD (APD). We reviewed our experience, to assess if these improvements had any impact on patient and technique survival, comparing patients who started PD between 1986 and 1989 (group A), with those who started PD between 1990 and 1994 (group B). Both groups had a comparable basal comorbidity, except for a higher proportion of elderly patients in group B (mean age 48 vs 58 years, p < 0.01). The incidence of peritonitis was lower in group B, while there were no differences in the rates of catheter-related infection or hospital admission. Also, there were no significant differences in patients or technique survival. The increasing presence of elderly patients in our PD unit was, apparently, determinant for the evolution of patient survival. On the other side, technical improvements had a marginal impact on technique survival. A good general PD survival in both groups, with few patients changing to hemodialysis (HD), may explain the lack of significant differences. In addition, peritonitis and inadequate PD/ultrafiltration (UF) were replaced by abdominal surgical events and social reasons as the main causes for PD failure in the second phase of the study.

Natural anti-alpha-galactosyl antibodies in patients undergoing peritoneal dialysis and hemodialysis.

Anti-alpha-galactosyl antibodies (anti-Gal) seemingly mediate rejection of pig organs transplanted into humans and Old World monkeys. These natural antibodies appear to be produced by a subpopulation of B cells residing in the peritoneum. Therefore, peritoneal dialysis (PD) may have an impact on anti-Gal levels. In this cross-sectional study, blood anti-Gal levels were quantified by ELISA in 17 patients undergoing PD and 18 patients undergoing hemodialysis (HD), and the results were compared with those from a control group of 30 healthy blood donors. The effects of the mode of dialysis therapy and other epidemiologic variables on anti-Gal levels were also evaluated. The PD and HD patients were comparable with regards to age, sex, percentage having diabetes, time on dialysis, distribution of blood groups, and total serum levels of immunoglobulins A (IgA), G (IgG), and M (IgM). In patients and controls, IgG anti-Gal levels were not significantly different, but IgM anti-Gal levels were significantly lower in both PD and HD patients compared with controls. A nonsignificant trend toward lower IgM anti-Gal levels in PD patients compared with HD patients was also observed. IgG anti-Gal levels correlated positively with time on dialysis in the HD patients, but not in the PD patients. IgG anti-Gal levels also were found to be markedly elevated in three patients with chronic liver disease, but no other scrutinized variable appeared to influence IgG or IgM anti-Gal levels.

The economic cost of dialysis: a comparison between peritoneal dialysis and in-center hemodialysis in a Spanish unit.

We have studied the economic cost of dialysis therapy in our area (public setting) during 1994, comparing the cost of different modalities of in-center hemodialysis (HD) and home peritoneal dialysis (PD). Analyzed costs included: personnel, drug expenditure, disposable (dialysis- and non-dialysis-related), laboratory, other services, indirect costs, maintenance and redemption, hospital admissions, transport, and home supplies. The final cost per patient and year (in 1994 US$) was: hemodiafiltration (AN69 filter, bicarbonate buffer) $58,890; HD polymethylmethacrylate filter and bicarbonate buffer $55,076; HD cuprophane and acetate buffer $49,767; CAPD $31,201; and cost of automated PD $42,519. The main expenditure sections were: home supply and hospital admissions for PD patients, and personnel, drug expenditures, disposable dialysis material, indirect costs, hospital admissions, and transport for HD patients. Home peritoneal dialysis therapy has a significantly lower economic cost than any in-center HD modality.

Prevalence of microbial colonization in removed peritoneal catheters: a prospective study.

We conducted a prospective bacteriologic study of 89 peritoneal catheters removed from 77 peritoneal dialysis patients. Reasons for catheter removal included severe peritonitis (n = 36, Group A), persistent exit-site infection (n = 29, Group B), and dormant, seemingly uninfected catheters (n = 22, Group C). We studied the external cuff (EC) and internal cuff (IC) as well as the catheter tip. In Group A, microbial growth was seen in 86.1% of ECs, 66.7% of ICs, and 67.6% of tips. In cases of positive isolation, concordance was 91.7% IC versus EC, 84.2% IC versus tip, and 80.0% EC versus tip. The peritonitis agent was recovered from 61.1% of ECs, 50.0% of ICs, and 55.6% of tips. In Group B, colonization was seen in 72.4% of ECs, 44.8% of ICs, and 31.0% of tips. When an isolation was obtained from both EC and IC, concordance was 81.8%. The exit-site infection agent was recovered from 69% of ECs and 24% of ICs. In Group C, microbial growth was observed in 77.3% of ECs, 45.5% of ICs, and 31.8% of tips. Gram-positive bacteria predominated, with the same bacteria colonizing EC and IC in 66.7% of cases. In conclusion, removed peritoneal catheters present a high prevalence of extensive microbial colonization, even in the absence of overt infection.

Treatment of peritonitis in CAPD with ciprofloxacin: long-term experience.

We present the long-term results of a protocol of empirical monotherapy of continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis with ciprofloxacin. One hundred and fifteen episodes of peritonitis were studied. The treatment protocol included 5 days of intraperitoneal (IP) administration of the drug, followed by 10 days of oral therapy. A good clinical response was obtained in 83% of the cases, while treatment failure was observed in 4% and relapse in 7%. A decrease in the sensitivity to ciprofloxacin of the peritonitis agents was observed in the study, with Staphylococcus spp. in particular. Three episodes of peritonitis due to bacteria resistant in vitro to ciprofloxacin responded to the treatment protocol. Ciprofloxacin attained good plasma levels both after oral and IP administration. However, dialysate levels were poor after oral administration. The most frequent side effect was gastric intolerance to oral ciprofloxacin. Two patients experienced severe adverse reactions to the drug. Ciprofloxacin may be a good choice for empirical monotherapy of CAPD-related peritonitis. However, the emergence of bacterial resistances must be carefully monitored. The drug should be administered intraperitoneally, at least to induce remission of the infection. Side effects are not frequent, but ciprofloxacin should not be considered an innocuous drug.

Complications of permanent catheter implantation for peritoneal dialysis: incidence and risk factors.

We reviewed the incidence and risk factors for complications after insertion of permanent catheters for peritoneal dialysis (PD). We implanted 192 peritoneal catheters in 137 patients over ten years. Fifty-three complications were observed in 50 catheters (27.6%) implanted in 42 patients (30.6%): malposition or omental entrapment (13%), dialysate leak (8.9%), hemoperitoneum (3.6%), peritonitis (1%), surgical wound infection (0.5%), and chylous ascites (0.5%). The only significant risk factors for a complicated insertion were previous abdominal surgery, particularly if it affected the peritoneal membrane, and early use of the catheter after implantation (< 5 days), independent of surgical or closed insertion.