Clinical course and outcomes of single-organism Enterococcus peritonitis in peritoneal dialysis patients.

BACKGROUND AND OBJECTIVES: Enterococci are part of the normal flora of the gastrointestinal tract. They can cause enteric peritonitis, which is a serious complication of peritoneal dialysis (PD). However, the clinical course and outcome of PD-related Enterococcus peritonitis remains unclear. METHODS: We reviewed all Enterococcus peritonitis episodes occurring in our dialysis unit from 1995 to 2009. RESULTS: During the study period, 1421 episodes of peritonitis were recorded. Of 29 episodes (2.0%) that were attributable to single-organism Enterococcus, 12 episodes were caused by E. faecalis; 9, by E. faecium; and the remaining 8, by other Enterococcus species. The overall rate of ampicillin resistance was 41.4%. Recent use of antibiotics was associated with the development of ampicillin-resistant Enterococcus (ARE) peritonitis (hazard ratio: 12.53; p = 0.04). The primary response rate of Enterococcus peritonitis was significantly higher than that of Escherichia coli peritonitis (89.7% vs. 69.9%, p = 0.038), but the primary response rate was not significantly lower for ARE peritonitis than for ampicillin-susceptible Enterococcus (ASE) peritonitis (83.3% vs. 94.1%, p = 0.553). However, significantly more patients with ARE had received vancomycin (83.3% vs. 23.5%, p = 0.003), with a longer mean duration of vancomycin treatment (11.8 ± 6.9 days vs. 3.7 ± 6.8 days, p = 0.005). CONCLUSIONS: Recent use of antibiotics was a risk factor for the development of ARE peritonitis. Outcomes in ASE and ARE peritonitis were similar, but vancomycin was required during treatment for ARE peritonitis, in turn possibly predisposing the patients to infections caused by vancomycin-resistant organisms.

Colonic diverticulosis as a risk factor for peritonitis in Chinese peritoneal dialysis patients.

OBJECTIVES: The risk of development of enteric peritonitis in Chinese peritoneal dialysis (PD) patients with colonic diverticulosis is not known. There have been no reports on whether colonic diverticulosis may affect peritonitis outcomes. The objectives of this study were to examine whether colonic diverticulosis is a risk factor for the development of enteric peritonitis and to study its influence on the outcome of enteric peritonitis. PATIENTS AND METHODS: All continuous ambulatory PD patients that had barium enema and colonoscopic examinations performed between January 1994 and January 2006 were included. They were divided into 2 groups: patients with diverticulosis and patients without diverticulosis. Their demographic and clinical characteristics, colonic examination findings, and peritonitis data were compared and analyzed. RESULTS: 104 Chinese patients received 110 colonoscopies and 51 barium enema examinations. 25 patients (24.0%) had colonic diverticulosis. Patients with diverticulosis were older (65.4 +/- 14.7 vs 58.4 +/- 14.0 years, p = 0.033). The most common site of involvement of diverticulosis was the ascending colon (56%). 128 episodes of enteric peritonitis were recorded in 49 patients. Compared with patients without enteric peritonitis, more patients in the enteric peritonitis group had diverticulosis (38.8% vs 10.9%, p = 0.001) and diverticulosis most often involved the ascending colon (20.4% vs 7.3%, p = 0.082). Multivariate logistic regression analysis showed that the presence of diverticulosis (hazard ratio 5.17, 95% confidence interval 1.86 - 14.40; p = 0.002) and diverticulosis involving the ascending colon (hazard ratio 6.89, 95% confidence interval 1.43 - 33.32, p = 0.016) were independent risk factors for the development of enteric peritonitis. Enteric peritonitis in patients with diverticulosis had a higher but nonsignificant treatment failure rate (26.9% vs 18.4%, p = 0.282). CONCLUSION: In this selected cohort of PD patients with indications of colonic examinations, diverticulosis, especially involving the ascending colon, may be a risk factor for the development of enteric peritonitis. Colonic diverticulosis does not appear to affect the outcome of enteric peritonitis. Further studies are warranted to determine ways to prevent enteric peritonitis in PD patients with diverticulosis.

A prospective randomized study comparing tenckhoff catheters inserted using the triple incision method with standard swan neck catheters.

BACKGROUND AND OBJECTIVE: The downward directed exit of the swan neck catheter may decrease the risk of exit-site infection (ESI). The percentage of migrations of the swan neck catheter seems to be less than the conventional Tenckhoff catheter and the swan neck catheter is more expensive and cannot be manipulated by guidewire technique if tip migration occurs. In this study, the conventional Tenckhoff catheter was used. The straight tunnel was converted to an arcuate one using the triple incision method, resulting in a downward directed exit. The arcuate tunnel was created by passing the catheter through an additional incision located between the paramedian incision and the exit site. We compared the infective and mechanical complications of the Tenckhoff catheter with a downward exit, implanted using the triple incision method, with the swan neck catheter. PATIENTS AND METHODS: 101 new peritoneal dialysis patients were prospectively randomized to receive either the Tenckhoff catheter with a downward exit, implanted using the triple incision method, or the swan neck catheter. Each patient was followed up for 24 months. 50 patients were in the triple incision method group (TIMG) and 51 were in the swan neck catheter group (SNCG). RESULTS: Over a mean period of 18.9 +/- 8.0 months of follow-up, ESI occurred in 35 patients (70%) in TIMG and 37 patients (72.5%) in SNCG (p = 0.83). The ESI rates were 0.71 and 1.0 episodes/catheter-year in TIMG and SNCG respectively (p = 0.21). The peritonitis rates were similar in the 2 groups (0.64 episodes/year in TIMG and 0.68 episodes/year in SNCG, p = 0.47). More patients in TIMG had tip migration [15 patients (30%) in TIMG vs 10 patients (19.6%) in SNCG] but the difference was not statistically significant. Repositioning of the catheter by guidewire manipulation was successful in patients in TIMG but not in SNCG. Overall catheter survival at 12 and 24 months was 95% and 83% in TIMG and 93% and 79% in SNCG respectively (p = 0.72). CONCLUSION: By using the conventional Tenckhoff catheter with a downward exit created using the triple incision method, high catheter survival rates with infective and mechanical complication rates similar to those of the swan neck catheter can be achieved. The triple incision method has the additional advantages of lower cost and the catheter can be manipulated by guidewire technique if tip migration occurs.

Response to adefovir or entecavir in renal allograft recipients with hepatitic flare due to lamivudine-resistant hepatitis B.

We studied the effects of adefovir or entecavir in six kidney transplant recipients (mean age 45.7 +/- 7.8 yr) who developed hepatitic flare due to lamivudine-resistant hepatitis B virus (HBV) infection, with 18 months of follow-up. All patients had elevated alanine aminotransferase (ALT) levels and HBV DNA >10(5) copies/mL (median 2.15 x 10(8) copies/mL) at baseline. Serum creatinine and creatinine clearance levels were 137.8 +/- 59.7 mumol/L and 62.6 +/- 18.7 mL/min, respectively. Four patients were treated with adefovir and two with entecavir. Median HBV DNA decreased to 1.99 x 10(5) copies/mL (p = 0.028) after six months, 1.5 x 10(4) copies/mL (p = 0.043) after 12 months, and 7.35 x 10(4) copies/mL (p = 0.068) after 18 months of treatment. There was a corresponding improvement in ALT (34.5 +/- 19.1 U/L after 18 months, p = 0.029 compared with baseline). The rate of HBV DNA suppression was variable, and three patients took over six months for the viral load to decrease to <10(5) copies/mL. After 18 months, HBV DNA was <10(5) copies/mL in four patients and <10(2) copies/mL in one patient. Treatment was well-tolerated and renal function remained stable. We conclude that both adefovir and entecavir are effective in the treatment of lamivudine-resistant HBV in renal allograft recipients, and the reduction of HBV DNA to <10(5) copies/mL could be slow.

Epstein syndrome presenting as renal failure in young patients.

Two young Chinese patients presented with renal failure and thrombocytopenia. Further investigations showed the presence of large platelets and high-frequency sensorineural hearing deficit. Genetic studies confirmed mutations in the gene encoding the myosin heavy chain (MYH-9), and Epstein Syndrome was diagnosed. One patient underwent deceased-donor kidney transplantation with satisfactory graft function. Epstein Syndrome is a rare genetic disorder with autosomal dominant inheritance. Clinicians should be aware of this entity when a young patient presents with renal failure and thrombocytopenia.

Retroperitoneal leakage as a cause of acute ultrafiltration failure: its associated risk factors in peritoneal dialysis.

BACKGROUND: Ultrafiltration failure is an important clinical problem in patients on maintenance peritoneal dialysis (PD) and is associated with high morbidity and mortality. Acute ultrafiltration failure (AUFF) is usually secondary to mechanical problems with the peritoneal catheter or peritoneal leakage. Retroperitoneal leakage (RPL) is an important cause of AUFF and often poses diagnostic difficulty. Herein we analyze the incidence of AUFF secondary to RPL in our centers and study its associated risk factors. METHODS: After excluding causes due to mechanical problems with the peritoneal catheter, patients complicated by AUFF underwent computerized tomographic peritoneography (CTP) or magnetic resonance imaging of the peritoneal cavity (MRP) to determine any RPL. Other patients on maintenance PD without RPL served as controls for comparison of risk factors. Demographic and peritoneal membrane characteristics, including history of hernia and pleuroperitoneal leakage, were analyzed. RESULTS: During the 5-year study period, 36 patients in a cohort of 743 patients on maintenance PD developed AUFF. 23 of these 36 patients were found to have RPL, which was confirmed by either CTP (n = 16) or MRP (n = 7). The duration of PD at the time of RPL and the dialysate-to-plasma ratio of creatinine at 4 hours were 49.3 +/- 24.5 (range 0.5 - 87.9) months and 0.70 +/- 0.09 respectively. Incidences of hernia (52.2%) and pleuroperitoneal communication (34.8%) were significantly higher than in PD patients without RPL (13% and 7% respectively, p = 0.001). Logistic regression analysis identified hernia and pleuroperitoneal communication as the risk factors for RPL. The odds ratios for RPL with hernia and pleuroperitoneal communication were 6.62 [95% confidence interval (CI) 2.35 - 18.69, p < 0.001] and 6.23 (95% CI 1.83 - 21.19, p = 0.003) respectively. CONCLUSION: RPL was not uncommon in patients with AUFF. A high index of suspicion for RPL is needed in the management of patients with history of hernia or pleuroperitoneal communication presenting with AUFF.

Management of hepatitis B reactivation in patients with lupus nephritis.

Hepatitis B is endemic in many Asian countries and immunosuppression may precipitate hepatitic flare. There is little data on the treatment of hepatitis B in patients with systemic lupus erythematosus. We monitored serial transaminase and HBV DNA levels in our HBsAg-positive patients with a history of lupus nephritis and instituted anti-viral treatment in patients who showed virological reactivation. This retrospective pilot study reports the data with this pre-emptive management strategy. Amongst 228 patients with lupus nephritis, eight (3.51%) were HBsAg-positive and five had received Lamivudine treatment for hepatitis B. In two patients the virological flares were preceded by lupus flares that necessitated an increase in immunosuppressive treatment. Median HBV DNA level was 1.9 x 10(7) copies/mL (range 1.2 x 10(4)-1.0 x 10(9) copies/mL) at baseline, and it decreased by 2-5 logs after treatment. Four patients had abnormal transaminase levels at baseline, with mean alanine aminotransferase at 125.0 +/- 67.4 U/L, and all achieved normalisation after 3-24 months (median 13 months) of treatment. Discontinuation of Lamivudine treatment was attempted in three patients after 9-15 months. In one patient treatment was recommenced because of virological flare. For the remaining two patients in whom treatment was not interrupted, one showed sustained viral suppression and one developed drug resistance. All antiviral treatments were well-tolerated. These results indicate the importance of serial monitoring of HBV DNA and transaminase levels, and prompt anti-viral therapy, in the management of HBsAg-positive lupus patients. Also, it may be feasible to discontinue treatment in stable patients to avoid the selection of drug-resistant variants.

Cost comparison between mycophenolate mofetil and cyclophosphamide-azathioprine in the treatment of lupus nephritis.

OBJECTIVE: To compare the healthcare expenditure associated with mycophenolate mofetil (MMF)-based immunosuppression in contrast to conventional therapy in patients with lupus nephritis. METHODS: Our retrospective single-center study compared the major healthcare costs during the first 24 months of treatment incurred by immunosuppressive medications, hospitalization, and complications in patients with severe lupus nephritis who had been treated with prednisolone and either MMF or sequential cyclophosphamide induction followed by azathioprine maintenance (CTX-AZA). RESULTS: Forty-four patients were studied (22 in each group). Baseline demographic and clinical measures, and remission rates after treatment, were similar between the 2 groups. Immunosuppressive drug cost was 13.6-fold higher in the MMF group (US$4168.3+/-1176.5 per patient, compared with $285.0+/-70.6 in the CTX-AZA group, mean difference $3883.2+/-251.3; p<0.001). MMF treatment was associated with a lower incidence of infections (12.0 episodes/1000 patient-months, compared with 32.4 in the CTX-AZA group; p=0.035). Combined cost of hospitalization and treatment of infections was 82.5% lower in the MMF group (mean difference -2208.7+/-1700.6; p=0.120). Overall treatment expenditure on immunosuppressive drugs, hospitalization, and treatment of infections was 1.57-fold higher in the MMF group (mean US $4635.9 compared with $2961.5 in the CTX-AZA group; p<0.001). CONCLUSION: While the cost of MMF treatment for severe lupus nephritis is much higher compared with CTX-AZA, the increased drug cost is partially offset by savings from the reduced incidence of complications.

Procalcitonin fails to differentiate inflammatory status or predict long-term outcomes in peritoneal dialysis-associated peritonitis.

BACKGROUND: Peritonitis is the major complication in patients undergoing maintenance peritoneal dialysis (PD) and is associated with a significant risk of mortality. Previously, we have shown that patients treated for peritonitis and having prolonged elevation of C-reactive protein (CRP) are associated with higher mortality. The underlying cause for the chronic systemic inflammation remains unknown. We studied serum procalcitonin (PCT), which has been reported as an accurate marker for infection and inflammation, with respect to being a diagnostic and prognostic indicator of persistent chronic inflammation after peritonitis in patients with PD-related peritonitis. METHODS: We conducted a prospective study on PD patients that developed PD-related peritonitis. Blood samples obtained at routine check-up before the onset of peritonitis were taken as baseline (D0). When patients developed PD-related peritonitis, serial blood samples were obtained on day 1 (D1), day 7 (D7), and day 42 (D42) for PCT, CRP, and other inflammatory markers. Patients were followed up for at least 2 years, during which outcomes of peritonitis and causes of death were recorded. Serum levels of CRP and PCT at day 42 were analyzed to assess for long-term prognosis. RESULTS: 35 patients [female 42.9%; mean age 63.8 +/- 13.1 years; 12 (34.3%) diabetics] were recruited. The onset of peritonitis was 3.61 +/- 3.56 years after PD initiation and median residual renal function at that time was 1.06 (range 0 - 6.1) mL/min. Median total white cell counts in PD effluent at days 1, 3, 7, and 42 were 3505/mm(3) (range 377 - 20 500/mm(3)), 297 (8 - 5880)/mm(3), 34 (0 - 5290)/mm(3), and 10 (0 - 115)/mm(3), respectively. Twelve (34.3%) and 14 (40%) PD effluents grew gram-positive and gram-negative micro-organisms respectively; others were culture negative. Median PCT was increased significantly at day 1 [2.00 (0.12 - 58.7) ng/mL, p < 0.001], day 7 [0.76 (0.13 - 15.25) ng/mL, p < 0.001], and day 42 [0.30 (0.13 - 0.79) ng/mL, p = 0.005] compared to baseline [0.20 (0.09 - 0.69) ng/mL]. Seven of 35 patients had false-negative results on day 1 (range 0.12 - 0.46) when PCT <0.5 ng/mL was used as the cutoff value for diagnosing peritonitis. For the long-term prognostic outcome, CRP at day 42 was significantly better than PCT in assessing overall prognosis (CRP: AUC 0.712, 95% CI 0.534 - 0.890 vs PCT: AUC 0.652, 95% CI 0.448 - 0.855). In Kaplan-Meier survival analysis, patients with elevated CRP (>3.0 mg/L) were associated with poorer long-term survival (p = 0.04) but elevated PCT at the 25th, 50th, or 75th percentiles failed to provide prognostic value. CONCLUSIONS: PD patients after peritonitis may be associated with prolonged systemic inflammation. CRP was a better serum marker for monitoring inflammatory status and predicting long-term prognosis in our study. Although serum PCT is elevated in some patients at the time of peritonitis, its value in making a diagnosis and predicting long-term prognosis remains doubtful.

Clinicopathologic analysis of renal biopsies after haematopoietic stem cell transplantation.

AIM: The ever-growing number and increasing survival of haematopoietic stem cell transplantation (HSCT) allow better recognition of its associated renal injuries. We aimed to study the clinicopathologic features of renal biopsies after HSCT by reviewing 13 percutaneous renal biopsies in our institute (Queen Mary Hospital). METHODS: A retrospective clinicopathologic study of all renal biopsies archived to the Department of Pathology, Queen Mary Hospital during the period January 1999 to December 2006 was performed. Biopsies from patients with HSCT were selected. Clinical data on presentation and follow up were retrieved from hospital records and physicians. RESULTS: In the 8-year period, a total of 2233 native renal biopsies were archived. Thirteen renal biopsies were selected from 12 patients with HSCT (11 allogeneic, one autologous). All but one patient were male. The age at renal biopsy ranged from 7 to 63 years (median: 32 years). The median interval of renal biopsy after HSCT was 24 months (range 1-134 months). Evidence of graft-versus-host disease was found in nine patients. The most common presentation was significant proteinuria (10 cases) and renal impairment (eight cases). The predominant histological changes were membranous glomerulonephritis (n = 4) and thrombotic microangiopathy (n = 4). One case of focal segmental glomerulosclerosis, IgA nephropathy, minimal change disease, acute tubular necrosis and hypertensive nephrosclerosis were also recorded. Four of our patients died at 0-11 months after renal biopsy. Of the remaining eight patients with a mean follow up of 43.6 months (range, 10-98 months), chronic renal impairment were found in three (37.5%) patients and significant proteinuria also persisted in three. One patient had cytogenetic evidence of relapse of underlying haematological malignancy after HSCT. CONCLUSION: Among the various renal lesions after HSCT, membranous glomerulonephritis and thrombotic microangiopathy were the most common. Mechanisms of renal injury varied from graft-versus-host disease-associated immune complex deposition to non-immune complex injury on endothelial cells, glomerular epithelial cells and tubular epithelium. Pathologists and clinicians should attend to the histological and temporal heterogeneity of renal injury when managing patients after HSCT.

Prospective controlled study on mycophenolate mofetil and prednisolone in the treatment of membranous nephropathy with nephrotic syndrome.

BACKGROUND: Retrospective and anecdotal data suggest that mycophenolate mofetil (MMF) might be effective when given as rescue therapy for membranous nephropathy (MN). Prospective controlled data on MMF and prednisolone as primary therapy are lacking. METHODS: A prospective, randomized, controlled, open-label study was performed to investigate the efficacy and tolerability of MMF and prednisolone as primary treatment in MN with nephrotic syndrome. MMF and prednisolone given for 6 months was compared against a modified Ponticelli regimen in 20 patients, with follow up of 15 months. RESULTS: MMF with prednisolone and the comparative immunosuppressive regimen showed similar efficacy in proteinuria reduction, despite a lower cumulative prednisolone dose in the MMF group (3.80 +/- 0.28 vs 9.93 +/- 0.25 g, P < 0.001). Remission (composite of 'complete' and 'partial') rates were 63.6% and 66.7% in the MMF group and control group, respectively (P = 1.000). Serum creatinine and creatinine clearance remained stable during follow up. Cumulative relapse rate was 23.1% at 2 years. Chlorambucil resulted in more leucopenia compared with MMF. CONCLUSION: Data from this pilot study indicate that more than 60% of patients with MN and nephrotic syndrome respond to combined MMF and prednisolone treatment, and suggest potential benefits of MMF as being steroid-sparing and having less adverse effects compared with other commonly used cytotoxic agents.

Risks and outcomes of peritonitis after flexible colonoscopy in CAPD patients.

OBJECTIVE: The ISPD 2005 guidelines for peritonitis recommend antibiotic prophylaxis for patients undergoing colonoscopy with polypectomy while on continuous ambulatory peritoneal dialysis (CAPD) but there is little literature to support this recommendation. This study aimed to look into the risks and outcomes of peritonitis after colonoscopy in CAPD patients. PATIENTS AND METHODS: All records of flexible colonoscopy performed on our CAPD patients from January 1994 to January 2006 were retrieved. Demographic and clinical data, use of antibiotics before colonoscopy, endoscopic findings, procedure performed, and peritonitis data were analyzed. RESULTS: 77 CAPD patients underwent 97 colonoscopies. No peritonitis developed in the 18 cases where antibiotics were given before colonoscopy. Among those without antibiotic prophylaxis, 4 episodes of peritonitis occurred within 24 hours after the procedure and 1 occurred 5 days later. All responded to intraperitoneal antibiotics. Colonic biopsy and polypectomy were not associated with more peritonitis (2 in 41 with biopsy vs 3 in 38 without biopsy, p = 0.67; 1 in 30 with polypectomy vs 4 in 49 without polypectomy, p = 0.64). CONCLUSION: The risk of peritonitis after colonoscopy without antibiotic prophylaxis was 6.3%. All peritonitis episodes responded to intraperitoneal antibiotics. Colonic biopsy or polypectomy did not appear to increase the risk of peritonitis. Although statistically not significant when compared with patients without antibiotic prophylaxis, we observed no peritonitis after colonoscopy in patients that were given antibiotics for prophylactic purposes or for other reasons. The efficacy of prophylactic antibiotics would be better defined by large randomized trials.

A cluster of rapidly growing mycobacterial peritoneal dialysis catheter exit-site infections.

In this case series, a cluster of 5 consecutive peritoneal dialysis patients with atypical mycobacterial exit-site infections in a single center within 20 months are described. Clinical features, treatment, and outcomes are discussed. Most patients had been treated with prolonged systemic antibiotic therapy for recurrent bacterial exit-site infections in the preceding months, and all had used topical gentamicin ointment for exit-site infection treatment or prophylaxis. It is postulated that this might have predisposed them to atypical mycobacterial exit-site infection as a result of selection pressure on uncommon organisms.

Tuberculous lymphadenitis in patients undergoing continuous ambulatory peritoneal dialysis.

The aim of this study was to review the clinical features of tuberculous (TB) lymphadenitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Nine cases of TB lymphadenitis were diagnosed among 910 patients over a period of 10 years. There were five men and four women with a mean age of 51 +/- 15.5 years. The TB lymphadenitis involved the cervical lymph nodes in six patients, supraclavicular lymph nodes in two patients and mediastinal lymph nodes in one patient. Six patients presented with clinically enlarged lymph nodes of whom four also had fever. Three other patients were incidentally found to have enlarged lymph nodes on routine chest X-ray or ultrasound examination of the neck. Diagnosis of TB lymphadenitis was made by demonstrating caseating granulomata with or without positive acid-fast bacilli on excisional lymph node biopsy. All patients were cured with standard anti-tuberculosis drugs for 12 months. No recurrence of the TB lymphadenitis was observed after a mean follow-up of 59 +/- 30 months. We conclude that TB lymphadenitis is not uncommon among patients on CAPD. A high index of suspicion is needed for early diagnosis of this condition. Prompt initiation of anti-tuberculosis treatment is associated with good prognosis.

Hyperleptinaemia and chronic inflammation after peritonitis predicts poor nutritional status and mortality in patients on peritoneal dialysis.

BACKGROUND: The serum leptin level is elevated in patients undergoing peritoneal dialysis (PD) and associated with a loss of lean body mass. The nutritional status of PD patients may further be worsened following peritonitis. We investigated the association between hyperleptinaemia, inflammation and malnourishment in PD-related peritonitis. METHODS: We conducted a prospective study on PD patients who developed peritonitis. Blood samples were obtained as baseline (D0) before the onset of peritonitis, and once peritonitis developed, leptin, adiponectin (ADPN) and other inflammatory markers were collected, on day 1 (D1), day 7 (D7) and day 42 (D42) of peritonitis. Patients were followed-up for any censor event or 1 year after peritonitis. RESULTS: Forty-two patients with a mean age of 62.9+/-13.2 years were recruited. Fourteen (33.3%) were diabetic. The serum leptin levels increased significantly from baseline to day 1 and 7, but fell back to the premorbid state at day 42. In contrast, the ADPN level decreased from a baseline value of 15.60+/-10.4 microg/ml to 13.01+/-8.1 microg/ml on day 1 (P=0.01) but rose to 14.39+/-8.9 microg/ml on day 7 (P=0.28) and 13.87+/-7.9 microg/ml on day 42 (P=0.21). High-sensitivity C-reactive protein (hs-CRP) increased significantly from baseline to day 1, 7 and even at day 42. The lean body mass (LBM) and nutritional markers decreased significantly after peritonitis. For patients with high hs-CRP (>3.0 mg/l) at day 42, there was a higher mortality rate than for those with lower hs-CRP (<3.0 mg/l, P=0.02), even if they were in clinical remission of peritonitis. CONCLUSIONS: Our study confirmed an increase in serum leptin during acute peritonitis and a prolonged course of systemic inflammation after apparent clinical remission of peritonitis. These factors related to the persistent chronic inflammation may contribute to the development of malnourishment and poor survival rate.

Pilot study of pegylated interferon-alpha 2a in dialysis patients with chronic hepatitis C virus infection.

AIM: Pegylated interferon (PEG-IFN) combined with ribavirin is recommended for the treatment of chronic hepatitis C virus (HCV) infection in patients without renal failure. The optimal treatment of hepatitis C in dialysis patients remains to be established. A high incidence of adverse effects has been observed with conventional interferon and PEG-IFN alpha-2b in dialysis patients. METHODS: We conducted a prospective study to investigate the tolerability and efficacy of PEG-IFN alpha-2a (135 microg weekly for 48 weeks) in six dialysis patients with chronic HCV infection. RESULTS: Two patients completed 48 weeks of treatment. Treatment was stopped in three patients (beyond 24 weeks) when they developed unrelated complications, and stopped in one patient due to failure of viral clearance. None required treatment discontinuation due to adverse effects, and PEG-IFN alpha-2a was subjectively well tolerated. Marrow suppression with mild anaemia, leucopenia, or thrombocytopenia remained common. Two patients (infected with genotypes 3a and 1b, respectively) had sustained virological response. CONCLUSIONS: Results from this pilot study showed that PEG-IFN alpha-2a appeared relatively well tolerated in dialysis patients with chronic HCV infection, and about one-third of patients could achieve sustained virological response.