A nephrologist dream of peritoneal dialysis catheter with zero migration: A multicenter prospective study.

INTRODUCTION: PD catheter tip migration is a common complication and a significant cause of catheter malfunction. In this perspective, we present our experience with a new catheter and a new technique that involves the use of a new triple cuff PD catheter and a low entry site in an attempt to prevent PD catheter migration. METHODS: A total of 503 incident PD patients have been studied in more than one PD center over a period of 5 years. RESULTS: During the 5-year follow up we recorded zero percent catheter migration. Other technical complications were poor drainage in 3.4%, omental wrap in 2.8%, early leakage in 3.4%, and catheter replacement in 2.4%. By the end of the study, the one-year PD catheter survival was 97.6%. CONCLUSION: Our new triple cuff PD catheter and our low-entry approach seem to be effective in preventing PD catheter migration and minimizing other mechanical complications.

Patients' awareness of their rights: An insight from a teaching hospital in Saudi Arabia.

BACKGROUND AND AIM: Knowledge and awareness of patients' rights are essential to reach the highest quality of care. In 2006, the Saudi Arabian government formulated "The Patients' Bill of Rights" to ensure that healthcare delivery is at its highest standard. Despite their efforts, several studies revealed patients' lack of awareness. In this study, we aim to investigate the patients' awareness of their rights according to the policy of a teaching hospital in Saudi Arabia. METHODS: A cross-sectional study was conducted where the participants (n= 384) were in-patients and out-patients of a tertiary care teaching hospital in the Eastern Province of Saudi Arabia. Informed consent was obtained, and confidentiality was maintained. The questionnaire consisted of 23 questions. Data were analyzed using Statistical Package Social Software version 26. RESULTS: Most of the participants were males (70.1%), in-patients (63.3%), and Saudi nationals (84.5%) with a mean age of 32 years. The mean awareness score was satisfactory (>7/14). However, more than half of the participants were unaware of their right to know the risks and benefits of treatment (55.1%), to know the identity of their healthcare providers (61.9%), to deny participation in research (58%), and appoint a healthcare proxy (64.8%). CONCLUSIONS: The present study revealed the lack of awareness of certain aspects of patients' rights that require action in the means of hospital awareness campaigns and educational materials. Further research is required to generalize a consensus on the Saudi population's level of awareness and consequent steps to optimize the delivery of healthcare in the country.

Peritoneal catheter insertion: combating barriers through policy change.

Barriers to accessing home dialysis became a matter of life and death for many patients with kidney failure during the coronavirus disease 2019 (COVID-19) pandemic. Peritoneal dialysis (PD) is the more commonly used home therapy option. This article provides a comprehensive analysis of PD catheter insertion procedures as performed around the world today, barriers impacting timely access to the procedure, the impact of COVID-19 and a roadmap of potential policy solutions. To substantiate the analysis, the article includes a survey of institutions across the world, with questions designed to get a sense of the regulatory frameworks, barriers to conducting the procedure and impacts of the pandemic on capability and outcomes. Based on our research, we found that improving patient selection processes, determining and implementing correct insertion techniques, creating multidisciplinary teams, providing appropriate training and sharing decision making among stakeholders will improve access to PD catheter insertion and facilitate greater uptake of home dialysis. Additionally, on a policy level, we recommend efforts to improve the awareness and feasibility of PD among patients and the healthcare workforce, enhance and promulgate training for clinicians-both surgical and medical-to insert PD catheters and fund personnel, pathways and physical facilities for PD catheter insertion.

Coexistence of Interstitial Nephritis and the Cellular Variant of Focal Segmental Glomerulosclerosis Secondary to Anabolic Steroid Abuse.

Anabolic-androgenic steroids (AAS) have been widely used by young people to enhance performance and increase muscle mass. The use of AAS can affect the kidneys and lead to a myriad of presentations, ranging from mildly elevated serum creatinine and blood urea nitrogen to irreversible chronic kidney disease and focal segmental glomerulosclerosis (FSGS). To the best of our knowledge, the coexistence of interstitial nephritis and the cellular variant of FSGS [Immunoglobulin M (IgM)] secondary to AAS abuse has not been previously reported in the literature. Here, we report the case of a 40-year-old bodybuilder who developed simultaneous interstitial nephritis and the cellular variant of FSGS (IgM) after short-term use of AAS and other dietary supplements.

Factors Contributing to Peritonitis in Peritoneal Dialysis: Comparing Triple Cuff Saudi Catheter to Double Cuff Tenckhoff Catheter: A 12-Year Observational Study.

Very few detailed descriptive studies focusing on peritonitis in patients on peritoneal dialysis (PD) have been published. Most of the current information is available through from either study with the limited number of patients or isolated case reports. We conducted an observational study of our PD-peritonitis database over the past 12 years to study the clinical profile and the outcomes of peritonitis episodes in our PD center. A total of 1123 patients (male: 59.5%) with 319 episodes of peritonitis were identified. Of the patients, 130 (11.6%) were considered immunocompromised (steroid use, failed renal transplant, systemic lupus erythematosus, malignancy) and 468 (41.7%) had diabetes mellitus. The total number of bacterial peritonitis episodes was 319; of these 226 (70.8%) were seen with double cuff Tenckhoff PD catheter and 93 (29.2%) occurred with triple-cuff Saudi PD catheter (P = 0.0001). Of all peritonitis episodes 170 (53.3%) episodes were caused by a single Gram-positive organism, 124 (38.9%) episodes by a single Gram-negative organism, and 25 (7.8%) were polymicrobial. Coagulase-negative staphylococci were responsible for most cases of Gram-positive peritonitis (n = 110, 64.7%), while Escherichia coli was the causative organism in 67 (54.0%) of the single Gram-negative episodes. Peritonitis episodes due to Gram-positive organisms had a better outcome than those caused by Gram-negative bacteria. Fifteen (4.7%) of the 319 episodes resulted in death in 13 patients. In 79 (24.8%) episodes, the patients had to be transferred to hemodialysis because of unresolved peritonitis. Resolution rate was 75.2% (240 episodes) which was influenced by PD catheter type, PD duration and the number of days peritoneal fluid effluent remained above 100 cells/µL. Other modifiable and non-modifiable factors had no effect on the resolution rate. Peritonitis episodes due to Gram-positive organisms had a better outcome than those with Gram-negative or polymicrobial etiology. Peritonitis resolution rates were worse with Staphylococcus aureus and Pseudomonas aeruginosa infections. Diabetes, current steroid use, and exit-site/tunnel infections seemed to have limited influence on the peritonitis outcome. Type of PD catheter (double Tenckhoff vs triple-cuff Saudi catheter), duration of PD and the number of days peritoneal fluid effluent remained >100 cells/µL were the only factors with significant effects on the outcome.

ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 update (adults).

SUMMARY STATEMENTS: (1) Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings (1B). GUIDELINE 2: ACCESS AND FLUID DELIVERY FOR ACUTE PD IN ADULTS: (2.1) Flexible peritoneal catheters should be used where resources and expertise exist (1B) (optimal).(2.2) Rigid catheters and improvised catheters using nasogastric tubes and other cavity drainage catheters may be used in resource-poor environments where they may still be life-saving (1C) (minimum standard).(2.3) We recommend catheters should be tunnelled to reduce peritonitis and peri-catheter leak (practice point).(2.4) We recommend that the method of catheter implantation should be based on patient factors and locally available skills (1C).(2.5) PD catheter implantation by appropriately trained nephrologists in patients without contraindications is safe and functional results equate to those inserted surgically (1B).(2.6) Nephrologists should receive training and be permitted to insert PD catheters to ensure timely dialysis in the emergency setting (practice point). (2.7) We recommend, when available, percutaneous catheter insertion by a nephrologist should include assessment with ultrasonography (2C).(2.8) Insertion of PD catheter should take place under complete aseptic conditions using sterile technique (practice point).(2.9) We recommend the use of prophylactic antibiotics prior to PD catheter implantation (1B).(2.10) A closed delivery system with a Y connection should be used (1A) (optimal). In resource poor areas, spiking of bags and makeshift connections may be necessary and can be considered (minimum standard).(2.11) The use of automated or manual PD exchanges are acceptable and this will be dependent on local availability and practices (practice point). GUIDELINE 3: PERITONEAL DIALYSIS SOLUTIONS FOR ACUTE PD: (3.1) In patients who are critically ill, especially those with significant liver dysfunction and marked elevation of lactate levels, bicarbonate containing solutions should be used (1B) (optimal). Where these solutions are not available, the use of lactate containing solutions is an alternative (practice point) (minimum standard).(3.2) Commercially prepared solutions should be used (optimal). However, where resources do not permit this, then locally prepared fluids may be life-saving and with careful observation of sterile preparation procedure, peritonitis rates are not increased (1C) (minimum standard).(3.3) Once potassium levels in the serum fall below 4 mmol/L, potassium should be added to dialysate (using strict sterile technique to prevent infection) or alternatively oral or intravenous potassium should be given to maintain potassium levels at 4 mmol/L or above (1C).(3.4) Potassium levels should be measured daily (optimal). Where these facilities do not exist, we recommend that after 24 h of successful dialysis, one consider adding potassium chloride to achieve a concentration of 4 mmol/L in the dialysate (minimum standard) (practice point). GUIDELINE 4: PRESCRIBING AND ACHIEVING ADEQUATE CLEARANCE IN ACUTE PD: (4.1) Targeting a weekly Kt/Vurea of 3.5 provides outcomes comparable to that of daily HD in critically ill patients; targeting higher doses does not improve outcomes (1B). This dose may not be necessary for most patients with AKI and targeting a weekly Kt/V of 2.2 has been shown to be equivalent to higher doses (1B). Tidal automated PD (APD) using 25 L with 70% tidal volume per 24 h shows equivalent survival to continuous venovenous haemodiafiltration with an effluent dose of 23 mL/kg/h (1C).(4.2) Cycle times should be dictated by the clinical circumstances. Short cycle times (1-2 h) are likely to more rapidly correct uraemia, hyperkalaemia, fluid overload and/or metabolic acidosis; however, they may be increased to 4-6 hourly once the above are controlled to reduce costs and facilitate clearance of larger sized solutes (2C).(4.3) The concentration of dextrose should be increased and cycle time reduced to 2 hourly when fluid overload is evident. Once the patient is euvolemic, the dextrose concentration and cycle time should be adjusted to ensure a neutral fluid balance (1C).(4.4) Where resources permit, creatinine, urea, potassium and bicarbonate levels should be measured daily; 24 h Kt/Vurea and creatinine clearance measurement is recommended to assess adequacy when clinically indicated (practice point).(4.5) Interruption of dialysis should be considered once the patient is passing >1 L of urine/24 h and there is a spontaneous reduction in creatinine (practice point).The use of peritoneal dialysis (PD) to treat patients with acute kidney injury (AKI) has become more popular among clinicians following evidence of similar outcomes when compared with other extracorporeal therapies. Although it has been extensively used in low-resource environments for many years, there is now a renewed interest in the use of PD to manage patients with AKI (including patients in intensive care units) in higher income countries. Here we present the update of the International Society for Peritoneal Dialysis guidelines for PD in AKI. These guidelines extensively review the available literature and present updated recommendations regarding peritoneal access, dialysis solutions and prescription of dialysis with revised targets of solute clearance.

Successfully treating three patients with acute kidney injury secondary to COVID-19 by peritoneal dialysis: Case report and literature review.

Coronavirus Disease 2019 (COVID-19) is a pandemic disease that increased the burden on health-care system. In the Kingdom of Saudi Arabia, 74,795 cases have been reported until 26 May 2020 and the number of cases is rapidly increasing. The mortality rate of COVID-19 worldwide is 6.37%. Here we report three cases of acute kidney injury (AKI) secondary to pneumonia of severe COVID-19; they were treated with automated peritoneal dialysis (PD) with full recovery. To the best of our knowledge, few reports in the literature have discussed the use of PD in AKI secondary to COVID-19.

Meropenem at recommended dose is a potential risk for seizure in hemodialysis patient.

Dosage adjustment of meropenem is usually recommended in hemodialysis (HD) patients and about 30% of meropenem is cleared during regular HD sessions. However, most of the published trials excluded patients on regular HD. Little is known about the accurate dosage of meropenem needed to avoid central nervous system toxicity. Herein, we report a 65-year-old Saudi female, a known case of end-stage renal disease on regular HD, who was admitted because of pyelonephritis and started on meropenem in the recommended dose according to cultures and sensitivity. She developed tonic-clonic convulsions after the 7th dose. Seizures were completely aborted after discontinuation of the offending drug. The recommended dosage of 500 mg daily in HD patients may still be too high particularly in Asian patients owing to their relatively small body mass index.

Exome sequencing of Saudi Arabian patients with ADPKD.

Purpose: Autosomal dominant polycystic kidney disease (ADPKD) is characterized by progressive development of kidney cysts and enlargement and dysfunction of the kidneys. The Consortium of Radiologic Imaging Studies of the Polycystic Kidney Disease (CRISP) cohort revealed that 89.1% had either a PKD1 or PKD2 mutation. Of the CRISP patients with a genetic cause detected, mutations in PKD1 accounted for 85%, while mutations in the PKD2 accounted for the remaining 15%. Here, we report exome sequencing of 16 Saudi patients diagnosed with ADPKD and 16 ethnically matched controls. Methods: Exome sequencing was performed using combinatorial probe-anchor synthesis and improved DNA Nanoballs technology on BGISEQ-500 sequencers (BGI, China) using the BGI Exome V4 (59 Mb) Kit. Identified variants were validated with Sanger sequencing. Results: With the exception of GC-rich exon 1, we obtained excellent coverage of PKD1 (mean read depth = 88) including both duplicated and non-duplicated regions. Of nine patients with typical ADPKD presentations (bilateral symmetrical kidney involvement, positive family history, concordant imaging, and kidney function), four had protein truncating PKD1 mutations, one had a PKD1 missense mutation, and one had a PKD2 mutation. These variants have not been previously observed in the Saudi population. In seven clinically diagnosed ADPKD cases but with atypical features, no PKD1 or PKD2 mutations were identified, but rare predicted pathogenic heterozygous variants were found in cystogenic candidate genes including PKHD1, PKD1L3, EGF, CFTR, and TSC2. Conclusions: Mutations in PKD1 and PKD2 are the most common cause of ADPKD in Saudi patients with typical ADPKD. Abbreviations: ADPKD: Autosomal dominant polycystic kidney disease; CFTR: Cystic fibrosis transmembrane conductance regulator; EGF: Epidermal growth factor; MCIC: Mayo Clinic Imaging Classification; PKD: Polycystic kidney disease; TSC2: Tuberous sclerosis complex 2.

Tidal peritoneal dialysis versus ultrafiltration in type 1 cardiorenal syndrome: A prospective randomized study.

BACKGROUND: Ultrafiltration is an alternative strategy to diuretic therapy for the treatment of patients with acute decompensated heart failure. Little is known about the efficacy and safety of peritoneal dialysis in patients with acute decompensated heart failure complicated by acute cardiorenal syndrome. METHODS: We randomly assigned a total of 88 patients with type 1 acute cardiorenal syndrome to a strategy of ultrafiltration therapy (44 patients) or tidal peritoneal dialysis (44 patients). The primary endpoint was the change from baseline in the serum creatinine level and left ventricular function represented as ejection fraction, as assessed 72 and 120 h after random assignment. Patients were followed for 90 days after discharge from the hospital. RESULTS: Ultrafiltration therapy was inferior to tidal peritoneal dialysis therapy with respect to the primary endpoint of the change in the serum creatinine levels at 72 and 120 h (p = 0.041) and ejection fraction at 72 and 120 h after enrollment (p = 0.044 and p = 0.032), owing to both an increase in the creatinine level in the ultrafiltration therapy group and a decrease in its level in the tidal peritoneal dialysis group. At 120 h, the mean change in the creatinine level was 1.4 ± 0.5 mg/dL in the ultrafiltration therapy group, as compared with 2.4 ± 1.3 mg/dL in the tidal peritoneal dialysis group (p = 0.023). At 72 and 120 h, there was a significant difference in weight loss between patients in the ultrafiltration therapy group and those in the tidal peritoneal dialysis group (p = 0.025). Net fluid loss was also greater in tidal peritoneal dialysis patients (p = 0.018). Adverse events were more observed in the ultrafiltration therapy group (p = 0.007). At 90 days post-discharge, tidal peritoneal dialysis patients had fewer rehospitalization for heart failure (14.3% vs 32.5%, p = 0.022). CONCLUSION: Tidal peritoneal dialysis is a safe and effective means for removing toxins and large quantities of excess fluid from patients with intractable heart failure. In patients with cardiorenal syndrome type 1, the use of tidal peritoneal dialysis was superior to ultrafiltration therapy for the preservation of renal function, improvement of cardiac function, and net fluid loss. Ultrafiltration therapy was associated with a higher rate of adverse events.

Pattern of renal diseases and the need for establishment of renal biopsy registry in Saudi Arabia.

Renal disease is a common medical problem in Saudi Arabia. Varieties of renal lesions if not treated properly or not discovered early will lead to a chronic kidney disease. Identifying the types of renal lesions can help in identifying the high-risk patients and appropriate treatment can be provided. Glomerulonephritis (GN) is considered one of the leading causes of end-stage renal disease in Saudi Arabia. The prevalence of different renal lesions were identified by different reports; however, these reports showed inconsistency. One important reason for such differences is related to the lack of unified methods in diagnosing and processing renal tissues and to the fact that different reports were reported by different pathologists. In addition, the differences in the reported results may reflect patient selection biases for renal biopsy or to the different policies and protocols adopted by different nephrologists. This is a prospective, multicenter study that involves different patients from different institutes and from different regions in Saudi Arabia to delineate the pattern of renal diseases based on renal biopsies. Four hundred and five cases were selected and studied over two years. This preliminary report shows that the most common primary renal lesion in Saudi Arabia is focal segmental glomerulosclerosis in 24.1%, followed by IgA nephropathy (15.2%), mesangioproliferative non-IgA, (13.2%), and membranoproliferative GN (12.4%). Lupus nephritis was the most common cause of secondary GN in 66% of the secondary causes.

Acute renal infarction induced by heavy marijuana smoking.

Acute renal infarction usually occurs in patients with severe atherosclerosis or valvular heart disease. We here report a 42-year Saudi male who presented with severe abdominal pain nausea and vomiting associated with hematuria, after heavy smoking of marijuana. Computed tomography abdomen revealed bilateral renal infarction. Serum anti phospholipids antibody and anti-cardio lipid antibody were positive. To the best of our knowledge, the association between marijuana and secondary lupus anticoagulant-induced renal infarction has not been reported previously.

Sarcoidosis with multiple organ involvement associated with necrotizing crescentic glomerulonephritis.

We report a case of a young Saudi male who presented with generalized body weakness and easy fatigability associated with fever, night sweating, loss of weight and appetite, and renal impairment. He was diagnosed as a case of sarcoidosis, and renal biopsy report was consistent with necrotizing crescentic glomerulonephritis (GN). Immunosuppressive medication was started to help halting the progression to renal failure and stabilize renal function. To the best of our knowledge, the association between sarcoidosis and crescentic GN has been reported in only few cases in literature.

Peritoneal Dialysis in Adult Patients with Permanent Suprapubic Catheter: A Single-Center Experience and Literature Review.

BACKGROUND: The aim of this paper was to review the feasibility of peritoneal dialysis (PD) in the presence of a permanent suprapubic catheter over a long follow-up period. METHODS: Twelve patients with automated PD and permanent suprapubic catheters were studied for complications over a period of 10 years. RESULTS: In all 12 patients, PD went smoothly. Two of our patients required removal of the PD catheter due to peritonitis. The overall rate of exit-site infection throughout the study was 41.7/patient-month and the difference between patients 60 years or older and those 25 years or younger was not significant (p = 0.3673). The overall peritonitis rate for all patients was 38.3 episode/patient-month, and none of the patients with ventriculoperitoneal shunt (VPS) had peritonitis. All patients with episodes of infection responded well to the proper antibiotics. CONCLUSIONS: The available data supported the feasibility of PD in patients with permanent suprapubic catheters; however, a greater number of patients with a longer follow-up period need to be studied to support our results.

Management of Salmonella peritonitis in a patient on peritoneal dialysis without catheter removal.

Peritoneal dialysis (PD)-associated peritonitis is an important contributor to morbidity and mortality; Gram-positive bacteria constitute the most frequent associated pathogens (45%-60%) followed by Gram-negative bacteria (25%-40%) and fungal infection (3%-6%). Salmonella peritonitis is an extremely rare cause of peritonitis (0.15%). Peritonitis attributed to Salmonella has been reported only in four cases. Herewith, we report a 68-year-old Sudanese female who presented to our PD unit with abdominal pain and diarrhea and was diagnosed to have Salmonella peritonitis. She was managed without catheter removal. To our knowledge, the association between Salmonella peritonitis due to Salmonella enteritidis in a patient on PD managed without catheter removal has been reported in only one case previously.

Acute Kidney Injury in Critically Ill Patients: A Prospective Randomized Study of Tidal Peritoneal Dialysis Versus Continuous Renal Replacement Therapy.

Few studies have discussed the role of peritoneal dialysis (PD) in managing acute kidney injury (AKI) in critically ill patients. The present study compares the outcome of AKI in intensive care unit (ICU) patients randomized to treatment with tidal PD (TPD) or continuous venovenous hemodiafiltration (CVVHDF). One hundred and twenty-five ICU patients with AKI were randomly allotted to CVVHDF, (Group A, N = 62) or TPD, (group B, N = 63). Cause and severity of renal injury were assessed at the time of initiating dialysis. The primary outcome was hospital mortality at 28 days, and secondary outcomes were time to recovery of renal function, duration of stay in the ICU, metabolic and fluid control, and improvement of sensorial and hemodynamic parameters. No statistically significant differences were observed between groups in regard to patients' characteristics. The survival at 28 days was significantly better in the patients treated with TPD when compared to CVVHDF (69.8% vs. 46.8%, P < 0.01). Infectious complications were significantly less (P < 0.01) in the TPD group (9.5%) when compared to the CVVHDF group (17.7%). Recovery of kidney function (60.3% vs. 35.5%), median time to resolution of AKI and the median duration of ICU stay of 9 days (7-11) vs. 19 days (13-20) were all in favor of TPD (P < 0.01). This study suggests that there are better outcomes with TPD compared to CRRT in the treatment of critically ill patients with AKI.

Successful treatment of acute renal failure secondary to complicated infective endocarditis by peritoneal dialysis: a case report.

BACKGROUND: Infective endocarditis is one of the most common infections among intravenous drug addicts. Its complications can affect many systems, and these can include acute renal failure. There is a scarcity of cases in the literature related to acute renal failure secondary to infective endocarditis treated with peritoneal dialysis. In this paper, the case of a 48-year-old Saudi male is reported, who presented with features suggestive of infective endocarditis and who developed acute kidney injury that was treated successfully with high tidal volume automated peritoneal dialysis. To our knowledge, this is the second report of such an association in the literature. CASE PRESENTATION: A 48-year-old Saudi gentleman diagnosed to have a glucose-6-phosphate dehydrogenase deficiency and hepatitis C infection for the last 9 years, presented to the emergency department with a history of fever of 2 days' duration. On examination: his temperature = 41 °C, there was clubbing of the fingers bilaterally and a pansystolic murmur in the left parasternal area. The results of the blood cultures and echocardiogram were supportive of the diagnosis of infective endocarditis, and the patient subsequently developed acute kidney injury, and his creatinine reached 5.2 mg/dl, a level for which dialysis is essential for the patient to survive. CONCLUSION: High tidal volume automated peritoneal dialysis is highly effective as a renal replacement therapy in acute renal failure secondary to infective endocarditis if no contraindication is present.

Milk-Alkali syndrome induced by H1N1 influenza vaccine.

Milk-Alkali syndrome (MAS) consists of a triad of hypercalcemia, metabolic alkalosis, and acute renal failure. We hereby report a 75-year-old Indian gentleman who presented to our emergency department with a history of generalized weakness and easy fatigability. Investigations were consistent with MAS secondary to calcium carbonate and calcitriol treatment to prevent osteoporosis, aggravated by H1N1 influenza vaccine. The patient was treated with hemodialysis and zoledronate. To our knowledge, this is the first reported case of such association in the literature.

Colonoscopy in automated peritoneal dialysis patients: value of prophylactic antibiotics: a prospective study on a single antibiotic.

OBJECTIVE: To evaluate the need for prophylactic antibiotics in automated peritoneal dialysis (APD) patients undergoing flexible colonoscopy. PATIENTS AND METHODS: A total of 93 patients on automated peritoneal dialysis (APD) undergoing diagnostic colonoscopy were enrolled in a prospective, randomized study. Patients were randomized into 2 age- and sex-matched groups; group A (46 patients) with intraperitoneal (IP) ceftazidime prior to colonoscopy and group B (47 patients) without prophylactic antibiotics. The relations between peritonitis and different parameters were analyzed. RESULTS: Of all colonoscopies, 60.2% showed normal findings, 17.2% with colonic polyps at different sites, 12.9% with angiodysplastic-like lesions, 5.4% with colonic ulcer(s), 3.2% with diverticulae without diverticulitis and 1.1% had transverse colon stricture. Post-colonoscopy peritonitis was documented in 3 (6.5%) and 4 (8.5%) patients in groups A and B, respectively (p = 0.2742); the causative organisms were mainly gram negative bacteria. Polypectomy was not associated with increased peritonitis episodes. By multiple logistic regression analysis, diabetes mellitus was the only independent variable that entered into the best predictive equation over the development of post-colonoscopy peritonitis but not antibiotic use. CONCLUSIONS: The relation between prophylactic antibiotic use prior to colonoscopy in APD patients and the risk of peritonitis was lacking. Only diabetes mellitus appears to be of significance. Polypectomy did not increase peritonitis episodes.

The Phantom of Metformin-Induced Lactic Acidosis in End-Stage Renal Disease Patients: Time to Reconsider with Peritoneal Dialysis Treatment.

♦ OBJECTIVE: Metformin continues to be the safest and most widely used antidiabetic drug. In spite of its well-known benefits; metformin use in end-stage renal disease (ESRD) patients is still restricted. Little has been reported about the effect of peritoneal dialysis (PD) on metformin clearance and the phantom of lactic acidosis deprives ESRD patients from metformin therapeutic advantages. Peritoneal dialysis is probably a safeguard against lactic acidosis, and it is likely that using this drug would be feasible in this group of patients. ♦ MATERIAL AND METHODS: The study was conducted on 83 PD patients with type 2 diabetes mellitus. All patients were on automated PD (APD). Metformin was administered in a dose of 500 - 1,000 mg daily. Patients were monitored for glycemic control. Plasma lactic acid and plasma metformin levels were monitored on a scheduled basis. Peritoneal fluid metformin levels were measured. In addition, the relation between plasma metformin and plasma lactate was studied. ♦ RESULTS: Mean fasting blood sugar (FBS) was 10.9 ± 0.5 and 7.8 ± 0.7, and mean hemoglobin A1-C (HgA1C) was 8.2 ± 0.8 and 6.4 ± 1.1 at the beginning and end of the study, respectively (p < 0.001). The mean body mass index (BMI) was 29.1 ± 4.1 and 27.3 ± 4.5 at the beginning and at the end of the study, respectively (p < 0.001). The overall mean plasma lactate level across all blood samples was 1.44 ± 0.6. Plasma levels between 2 and 3 mmol/L were found in 11.8% and levels of 3 - 3.6 mmol/L in 2.4% plasma samples. Hyperlactemia (level > 2 and ≤ 5 mmol/L) was not associated with overt acidemia. None of our patients had lactic acidosis (levels > 5 mmol/L). Age ≥ 60 was a predictor for hyperlactemia. No relationship was found between plasma metformin and lactate levels. ♦ CONCLUSION: Metformin may be used with caution in a particular group of ESRD patients who are on APD. Metformin allows better diabetic control with significant reduction of BMI. Information on the relationship between metformin and plasma lactate levels is lacking. Peritoneal dialysis appears to be a safeguard against the development of lactic acidosis in this group of patients.