Rhodotorula rubra peritonitis in patients undergoing continuous ambulatory peritoneal dialysis.

Although still uncommon, fungal peritonitis is being reported with increasing frequency in patients with renal failure who are undergoing long-term peritoneal dialysis. Although most cases have involved Candida albicans, other opportunistic pathogens have been reported as well. Recently, three patients were seen with serious peritoneal infections due to Rhodotorula rubra, a "nonpathogenic" fungus. In two patients, peritoneal fibrosis made further peritoneal dialysis impossible. The third patient died from complications of peritonitis. Environmental cultures revealed a possible common-source outbreak. Literature review reveals that infection due to this organism is most unusual and occurs only in the hospital setting in patients with serious compromise of host defenses.

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 among chronic renal failure patients requiring major abdominal surgery.

BACKGROUND: There is limited literature on survival of patients with chronic renal failure (CRF) who require major abdominal surgery. The goal of the present study was to evaluate indications for surgery and survival among dialysis patients undergoing major abdominal operations. STUDY DESIGN: Medical records for 26 CRF patients at our institution undergoing major nonvascular abdominal operations from 1990 to 1996 were reviewed. Results were evaluated by chi-square analysis. RESULTS: Surgery was performed emergently in 21 patients (81%) and electively in 5 patients (19%). The most common finding among the emergency surgery patients was ischemic colitis, occurring in 9 of 21 patients (43%). Postoperative (30-day) mortality among the emergency surgery patients was 38%. Longterm (1 year) survival was 28%. All 5 patients undergoing elective surgery are alive on followup of 1 to 5 years. The disparity in longterm survival between the emergency surgery versus the elective surgery patients was statistically significant (p = 0.004). CONCLUSIONS: Emergency surgery in patients with CRF is associated with poor survival rates. Colonic ischemia is a significant problem among these patients.

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.

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.

Salicylate nephropathy in the Gunn rat: potential role of prostaglandins.

We examined the potential role of prostaglandins in the development of analgesic nephropathy in the Gunn strain of rat. The homozygous Gunn rats have unconjugated hyperbilirubinemia due to the absence of glucuronyl transferase, leading to marked bilirubin deposition in renal medulla and papilla. These rats are also highly susceptible to develop papillary necrosis with analgesic administration. We used homozygous (jj) and phenotypically normal heterozygous (jJ) animals. Four groups of rats (n = 7) were studied: jj and jJ rats treated either with aspirin 300 mg/kg every other day or sham-treated. After one week, slices of cortex, outer and inner medulla from one kidney were incubated in buffer and prostaglandin synthesis was determined by radioimmunoassay. The other kidney was examined histologically. A marked corticomedullary gradient of prostaglandin synthesis was observed in all groups. PGE2 synthesis was significantly higher in outer medulla, but not cortex or inner medulla, of jj (38 +/- 6 ng/mg prot) than jJ rats (15 +/- 3) (p less than 0.01). Aspirin treatment reduced PGE2 synthesis in all regions, but outer medullary PGE2 remained higher in jj (18 +/- 3) than jJ rats (9 +/- 2) (p less than 0.05). PGF2 alpha was also significantly higher in the outer medulla of jj rats with and without aspirin administration (p less than 0.05). The changes in renal prostaglandin synthesis were accompanied by evidence of renal damage in aspirin-treated jj but not jJ rats as evidenced by: increased incidence and severity of hematuria (p less than 0.01); increased serum creatinine (p less than 0.05); and increase in outer medullary histopathologic lesions (p less than 0.005 compared to either sham-treated jj or aspirin-treated jJ). These results suggest that enhanced prostaglandin synthesis contributes to maintenance of renal function and morphological integrity, and that inhibition of prostaglandin synthesis may lead to pathological renal medullary lesions and deterioration of renal function.

The changing spectrum of heroin-associated nephropathy.

Thirty-five renal biopsies were performed on heroin abusers at our institution between January 1977 and June 1983 as part of the evaluation of unexplained heavy proteinuria. Twenty-eight patients (80%) had histopathologic diagnoses of either focal segmental glomerulosclerosis or renal amyloidosis. Patients having a diagnosis of renal amyloidosis were older (P = 0.025), had a longer history of heroin abuse (P = 0.05), and 13/14 demonstrated clear evidence of chronic subcutaneous suppurative lesions. The remaining seven patients demonstrated a spectrum of disease similar to that seen in the nonaddicted population. We compared the clinical and biopsy characteristics of patients evaluated between 1977 and 1980 with those seen between 1981 and 1983. The relative incidences of renal amyloidosis and focal glomerulosclerosis changed significantly (P = 0.025). Whereas 29% of patients in the early series had renal amyloidosis and 57% had focal glomerulosclerosis, the relative incidences in the later series were 48% and 29%, respectively. The development of renal amyloidosis in our patients appears to be related to a longer duration of heroin abuse with increased incidence of subcutaneous injection of the narcotic. Chronic, suppurative skin ulcerations tend to occur at the site of injection, resulting in a persistent acute-phase inflammatory state important for the initiation and potentiation of secondary amyloidosis.

Infectious diseases of the thyroid gland.

Clinical and laboratory characteristics of 224 patients with thyroidal infection reported since 1900 are reviewed. Much of the prior literature on this subject has assumed that most instances of thyroiditis are infectious and that all lymphomatous thyroiditis is tuberculous. Similarly, thyroiditis occurring with syphilis was often equated with treponemal invasion of the gland. Acute bacterial thyroiditis is rapid in onset and more likely than tuberculous infection to produce fever, pain, and tenderness. Suppurative and mycobacterial infections are most common among women with preexisting thyroid disorders. Mortality due to infectious thyroiditis is lower in cases covered by this review than has been previously reported. Gummatous and fungal infections of the thyroid are generally diagnosed only at biopsy or necropsy. Frequent thyroidal involvement in disseminated aspergillosis warrants careful investigation of the gland in patients with this infection. Echinococcosis of the thyroid is a chronic process that is generally diagnosed only following excision.

Markers for survival in dialysis: a seven-year prospective study.

Serum biochemical markers suggestive of undernutrition are directly correlated with mortality in hemodialysis and peritoneal dialysis patients. In particular, serum albumin is the most powerful predictor of survival. We have prospectively examined the relationship of single baseline measurements of serum albumin, cholesterol, creatinine, apoproteins, and prealbumin in 250 hemodialysis patients and 140 patients maintained on continuous ambulatory peritoneal dialysis (CAPD) monitored up to 7 years (1987 to 1994). Other variables studied included age, race, gender, diabetes, and number of months on dialysis. Observed survival was computed by the Kaplan-Meier method. Cox's proportional hazards model was used to determine independent predictors of mortality risk. Age, diabetes, prior months on dialysis, and low levels of serum albumin, creatinine, and cholesterol were important and independent predictors of mortality risk in hemodialysis patients. For peritoneal dialysis patients, the independent predictors of mortality risk were age, diabetes, and low serum albumin and serum creatinine. Prealbumin, a serum protein with rapid turnover and relatively small pool, was an important and independent risk predictor in both hemodialysis and CAPD patients. In addition, prealbumin was more highly correlated with other nutritional markers than was albumin. In summary, these findings suggest that biochemical measures associated with visceral and somatic protein depletion are predominant long-term mortality risk factors in patients maintained on hemodialysis and CAPD.

Predictive value of nutritional markers (albumin, creatinine, cholesterol, and hematocrit) for patients on dialysis for up to 30 years.

Mortality among end-stage renal disease patients in the United States remains unacceptably high despite progress in the management of renal replacement therapy. Consequently, there are few reports of long-term survivors on dialysis. We have analyzed characteristics of long-term (10 to 15 years, N = 40) and very long-term (15 to 30 years, N = 18) survivors on hemodialysis and long-term survivors (more than 10 years, N = 28) on peritoneal dialysis and compared them with "average survivors" (< 5 years, N = 65 for hemodialysis and N = 101 for peritoneal dialysis). Among hemodialysis patients, long- and very long-term survival was associated with younger age, nondiabetic status, black race, and male gender (P < 0.05 for all variables). Enrollment creatinine was higher among long- and very long-term survivors, whereas albumin and hematocrit increased significantly during the period of observation among long- and very long-term survivors compared with average survivors. Enrollment age, nondiabetic status, and albumin level predicted prolonged survival even after adjustments for confounding variables. Among peritoneal dialysis patients, younger age and nondiabetic status predicted prolonged survival. Black race was associated with improved survival, but the association was not statistically significant. Enrollment levels of albumin and creatinine were significantly higher among long-term survivors and the cholesterol increased during the period of observation in long-term survivors. Thus, demographic and biochemical indices reflecting nutritional status can predict prolonged survival in hemodialysis and peritoneal dialysis. Patient survival for periods of up to 30 years is possible on renal replacement therapy. Analyses of these outlier patients may offer clues to prolonged survival.

Prealbumin is the best nutritional predictor of survival in hemodialysis and peritoneal dialysis.

Patients undergoing dialytic therapy for end-stage renal disease (ESRD) have greater morbidity and mortality than age-matched individuals with similar demographics in the general population. Risk factors for early death during treatment for ESRD include advanced age, diabetes, hypertension, and malnutrition. We questioned whether the level of serum prealbumin at the start of uremia therapy might serve as a marker of subsequent survival in patients treated with maintenance hemodialysis (HD) and peritoneal dialysis (PD). Study cohorts included 111 HD and 78 PD patients followed for up to 5 years. Selected demographic characteristics and biochemical variables were tested for correlation with survival in each cohort. Variables evaluated included age, race, gender, diabetic status, and serum concentrations of albumin, creatinine, cholesterol, and prealbumin. For comparison, expected survival was calculated with Cox proportional hazards analysis, which accounts for confounding variables. We found that a higher relative risk (RR) of death in HD patients correlated with older age, the diagnosis of diabetes, and a serum prealbumin < 30 mg/dL. In PD patients, older age and the presence of diabetes correlated with a higher RR of death than in the standard population. When nutritional variables were analyzed separately, prealbumin < 30 mg/dL was the strongest variable that predicted mortality in HD patients (RR = 2.64, P = 0.002) and also predicted increased risk of mortality in PD patients (RR = 1.8, P = 0.035). Observed and expected survival was significantly higher in patients with enrollment prealbumin greater than 30 mg/dL in both HD and PD. The serum prealbumin level correlated significantly with other measures of nutrition, including serum albumin, serum creatinine, and serum cholesterol, in both HD and PD patients. Among tested markers of nutritional status, prealbumin level appears to be the single best nutritional predictor of survival in ESRD patients.

Safety and efficacy of guanabenz in hypertensive patients with moderate renal insufficiency.

Eight hypertensive patients with moderate renal insufficiency were treated with gradually increasing oral doses of guanabenz acetate to a maximum dose of 8 mg BID. Patients' medications were titrated over 8 weeks. Once blood pressure control was achieved (seated diastolic blood pressure, 90 mmHg, or decrease of 10 mmHg from baseline values), drug dosages were maintained for up to a 12-week total treatment phase. Patients had significant reductions of blood pressure during treatment with guanabenz as compared to that during pretreatment levels. No changes in body weight or creatinine clearance were evident, as compared to baseline values. Our data suggest that guanabenz, in relatively small doses, can be used as safe and effective monotherapy of essential hypertension in patients with moderate renal insufficiency.

Longitudinal survey of apolipoproteins and atherogenic risk in hemodialysis and continuous ambulatory peritoneal dialysis patients.

Total cholesterol (TC) and HDL-cholesterol (HDL-C) have been studied in dialysis patients, but a systematic study of apolipoprotein (apo) A-I, apo B, and the anti-atherogenic risk ratio, apo A-I/apo B, over time has not been done. We report lipid and apo values over 12-14 months in 55 hemodialysis (HD) and 40 continuous ambulatory peritoneal dialysis (CAPD) patients. For HD patients, mean TC fell, but not significantly, and HDL-C and TC/HDL-C, an atherogenic risk ratio, did not change over time. Apo A-I/apo B correlated with months on HD (r = 0.30, p less than 0.04) and rose significantly (p less than 0.005) during the study period. Paired t-test analysis by race, gender, and diabetes showed that in nondiabetics, apo A-I rose, apo B fell (p less than 0.05), and apo A-I/apo B improved (p less than 0.002). Similar trends were seen in all subgroups except for diabetics. For CAPD patients, total months of treatment correlated with TC/HDL-C (r = 0.46, p less than 0.05) and with HDL-C (r = -0.53, p less than 0.02), but paired t-test analysis of longitudinal data showed no significant changes in TC, HDL-C, apo A-I, apo B, TC/HDL-C, or apo A-I/apo B. The lipoprotein patterns of all patients who died were not significantly different from those of the surviving patients. Our longitudinal data reveal that lipids, apolipoproteins, and risk ratios remain stable over time on HD and CAPD. In fact, the anti-atherogenic index of apo A-I/apo B improved in HD patients, especially in nondiabetics.

Fall of cholesterol with time on dialysis: impact on atherogenicity.

The majority of patients treated for chronic renal failure die from cardiovascular complications. Lipid abnormalities in this group are thought to contribute to this high mortality. The authors have shown that hemodialysis patients with longer months on dialysis tend to have lower total cholesterol (TC) levels. This study extends data to examine lipid disturbances in 53 continuous ambulatory peritoneal dialysis (CAPD) and 126 hemodialysis patients using multivariate analysis. Longitudinal values after 9-10 months were measured in 16 CAPD patients and 52 hemodialysis patients. Analysis of covariance for all patients demonstrated an inverse correlation of TC (p = 0.003), high-density lipoprotein (HDL) cholesterol (p = 0.01), and apolipoprotein A-I levels (p less than 0.02) with months on dialysis. In addition, the TC level was higher in women (p less than 0.001) and CAPD patients (p less than 0.001), and correlated with age (p = 0.02) and albumin (p less than 0.001). HDL cholesterol was higher in blacks (p less than 0.001) but was not affected by gender, dialysis modality, age, or albumin. Diabetic status, serum parathyroid hormone, and blood pressure were not significant variables for TC or HDL-C. The atherogenic risk indicators, TC/HDL cholesterol (p less than 0.001) and apolipoprotein B (p less than 0.02) were higher in whites than in blacks. Longitudinal study revealed lower TC levels in individual hemodialysis patients (p less than 10(-6) by paired t-test), the fall being greater for patients with fewer total months on dialysis (p less than 0.04, by analysis of covariance). CAPD patients had no change in TC by paired t-test.(ABSTRACT TRUNCATED AT 250 WORDS)