Assessment of renal function during pregnancy using a random urine protein to creatinine ratio and Cockcroft-Gault formula.

The current standard for assessment of renal function in pregnant women is a 24-hour urine collection to determine creatinine clearance and proteinuria. It is easier to use the random urine protein to creatinine (P:C) ratio and the Cockcroft-Gault (CG) formula to estimate protein excretion and glomerular filtration rate, but the reliability of these formulae in combination for assessing renal function in pregnant women with renal disease is unknown. We compared the results of the P:C ratio with the 24-hour urinary protein excretion and the results of the CG clearance estimate with the 24-hour urine creatinine clearance in 34 pregnant women with underlying renal disease. Comparisons were made once in each trimester and postpartum. Prepregnancy weights were used in the CG formula: (140 - age x weight [kg] x 0.85)/72 x serum creatinine (mg/dL). Twenty-six first trimester, 33 second trimester, 21 third trimester, and 15 postpartum comparisons were made for creatinine clearance and 16 first trimester, 29 second trimester, 15 third trimester, and 15 postpartum comparisons were made for protein excretion. Measured creatinine clearance for the three trimesters combined (105 +/- 40 mL/min [mean +/- SD]) correlated significantly with CG clearances (113 +/- 52 mL/min; r = 0.87). The mean P:C values (2.03 +/- 3.15) for the three trimesters combined correlated significantly with 24-hour urine protein (2.25 +/- 4.21 g; r = 0.92). Our study demonstrates excellent correlations between the CG formula using prepregnancy weights and 24-hour creatinine clearance and between the P:C and 24-hour urinary protein in this population.(ABSTRACT TRUNCATED AT 250 WORDS)

Infecting organisms in continuous ambulatory peritoneal dialysis patients on the Y-set.

Disconnect systems for performing continuous ambulatory peritoneal dialysis (CAPD) use a flush-before-fill technique that should theoretically reduce the peritonitis caused by touch contamination. However, little information about the infecting organisms in CAPD-related infections using disconnect systems is available. We performed a retrospective matched-case controlled study to define the organisms responsible for the peritonitis and catheter infections seen in CAPD patients using the Y-set without disinfectant. One hundred nineteen patients who began CAPD on the Y-set were matched with 119 patients who began CAPD on the standard spike system. Patients were matched for age, sex, race, insulin dependence, and time on CAPD. Infection data were prospectively collected for all patients. Peritonitis, exit site, and tunnel infection rates (expressed as number of episodes per patient-year) were all significantly lower in the Y-set patients (0.56 v 0.94, 0.68 v 1.08, and 0.14 v 0.22, respectively). The lower peritonitis rate in the Y-set patients compared with that found in the standard spike system patients was due to a reduction in Staphylococcus epidermidis (0.17 v 0.26, P = 0.02), polymicrobial (0.014 v 0.06, P = 0.01), other gram-positive (0.007 v 0.09, P = 0.001), and sterile (0.10 v 0.19, P = 0.008) peritonitis. Rates of Staphylococcus aureus and gram-negative peritonitis were not different among the two groups. S epidermidis (0.12 v 0.23, P = 0.0014) and gram-negative (0.12 v 0.18, P = 0.04) exit site infection rates were also lower in the Y-set patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of providing chronic hemodialysis patients written material on advance directives.

Because little is known about the stability of knowledge, attitudes, and behavior toward advance directives in chronic hemodialysis patients, we chose to determine whether providing written information on advance directives affects chronic hemodialysis patients' knowledge, attitudes, and behavior toward advance directives over time. Various patient demographic factors were also assessed for association with the above parameters. Thirty-one chronic in-center hemodialysis patients (55% women, 48% African-Americans, 81% on dialysis for more than 3 years) completed a questionnaire consisting of patient demographic features and agreement or disagreement with statements concerning knowledge, attitudes, and behavior toward advance directives. The responses were scored from 1 (strongly agree) to 5 (strongly disagree). Patients completed the questionnaire before, shortly after (1 to 3 months), and distant to (6 to 7 months) receiving written information on advance directives. Receiving written information on advance directives did not improve patients' understanding of living wills (58% understood before, 77% shortly after, and 58% distant to receiving the information) and only transiently improved understanding of a health care proxy (32% before, 67% shortly after [P < 0.006], 55% distant [P = not significant]) and the hospital policy on advance directives (35% before, 61% shortly after [P < 0.02], 48% distant [P = not significant]). Patients' attitudes about advance directives and perceived barriers to their use were not different before, shortly after, or distant to receiving information. After receiving information on advance directives, more patients (13% before, 48% shortly after, 37% distant; P < 0.002) and their family members (10% before, 30% shortly after, 20% distant; P < 0.02) completed advance directives.(ABSTRACT TRUNCATED AT 250 WORDS)

Nephrologist-directed primary health care in chronic dialysis patients.

We previously found that chronic in-center hemodialysis patients relied on their nephrologists for the management of acute illnesses and comorbid chronic illnesses, such as diabetes mellitus and heart disease. Since chronic peritoneal dialysis differs from in-center hemodialysis, particularly in patients' exposure to nephrologists and other dialysis unit personnel, we asked chronic peritoneal dialysis patients about their reliance on nephrologists for general health care and compared their responses to those of in-center hemodialysis patients. A questionnaire consisting of patient demographic information and questions about primary medical care was completed by 118 chronic dialysis patients (74 in-center hemodialysis patients and 44 chronic peritoneal dialysis patients). Peritoneal dialysis patients were younger (mean age, 46 +/- 17 years v 56 +/- 17 years for hemodialysis patients, P < 0.005) and fewer had been on dialysis for more than 3 years (32% v 65%, P < 0.005). Seventy-one percent of all patients did not have a family physician (84 patients). More peritoneal dialysis patients had a family physician (43% v 20%, P < 0.025), but the proportion of hemodialysis and peritoneal dialysis patients who had seen their family physician within 6 months was similar (73% and 47%, respectively, P = 0.12). Most patients relied on their nephrologist for yearly physicals (80% of hemodialysis and 84% of peritoneal dialysis patients). More hemodialysis patients depended on nephrologists for the management of minor acute illnesses (91% v 64%, P < 0.005). At least 60% of chronic health problems were managed by the nephrologists and was not different among the two patient groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients on hemodialysis rely on nephrologists and dialysis units for maintenance health care.

The extent to which hemodialysis patients rely on nephrologists for primary medical care is unknown. The authors surveyed 74 in-center hemodialysis patients to obtain demographic data and information about primary medical care and subspecialty referrals and follow-up. Health care maintenance was also assessed. All patients were dialyzed in a free-standing university affiliated dialysis unit. The mean age of the patients was 55 +/- 17 years; most were women (43/74) and on hemodialysis more than 3 years (48/74). Most of the patients did not have a family physician and relied on the nephrologist for health maintenance care (80%) and the treatment of minor acute illnesses (91%). The most common non-renal chronic illnesses were gastrointestinal disease (32%), heart disease (26%), and diabetes (26%). Although referrals to subspecialists occurred in 55% of patients during the preceding year, nephrologists usually provided ongoing management care (gastrointestinal disease 21/24, heart disease 10/19, diabetes 12/19). Over half the women had a Papanicolaou's test within 3 years and 72% had a routine mammogram that, in most cases, had been ordered by the nurse practitioner or nephrologist. Because nephrologists provide primary medical care to the majority of dialysis patients, preventive health care protocols, such as mammography and cancer screening, should be incorporated into the nephrology practice in chronic dialysis units.

Increased risk of Staphylococcus epidermidis peritonitis in patients on dialysate containing 1.25 mmol/L calcium.

Peritoneal macrophage function is decreased in vitro in the presence of dialysate with 1.25 mmol/L calcium compared with that containing 1.75 mmol/L calcium. Theoretically, patients using this dialysate may have a higher risk of peritonitis. Nineteen patients on continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) were converted from dialysate with 1.75 mmol/L calcium (mean time, 33 +/- 26 months) to that with 1.25 mmol/L calcium, for some or all exchanges (mean time, 10 +/- 4.7 months). Peritonitis rates were compared with 19 control patients who remained on dialysate with 1.75 mmol/L calcium. The two groups were matched for the proportion of diabetics, sex, age, use of the Y-set, and dialysis modality (CAPD, CCPD). Peritonitis rates were similar in the study patients before conversion to 1.25 mmol/L calcium dialysate and in the control patients (0.49 v 0.58 episodes/patient-year, respectively). After conversion to dialysate with 1.25 mmol/L calcium, the peritonitis rate was 0.82 episodes/patient-year contrasted to 0.58 episodes/patient-year in the control patients (P = 0.09). The peritonitis rate due to Staphylococcus epidermidis was 0.51 episodes/patient-year when 1.25 mmol/L calcium dialysate was used, and 0.19 episodes/patient-year for the comparable period in the control patients on 1.75 mmol/L calcium dialysate (P = 0.005). The proportion of peritonitis episodes due to S epidermidis increased from 20% to 61% after conversion to 1.25 mmol/L calcium (P = 0.01). The increased risk of peritonitis due to S epidermidis in patients using dialysate with 1.25 mmol/L calcium is consistent with a previous study demonstrating that clearance of S epidermidis by peritoneal macrophages is less effective with a decrease in the dialysate calcium content.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for tunnel infections in continuous peritoneal dialysis.

Little data are available about risk factors for peritoneal catheter subcutaneous tunnel infection. Therefore, we analyzed tunnel infections occurring in our program over a 10.5-year period. One hundred twenty-nine tunnel infections occurred in 92 of 411 patients (22%) on peritoneal dialysis for a mean of 19 +/- 19 months. Tunnel infection rate was 0.19 per year. By 1 year, 15% of patients had a tunnel infection, and by 2 years, 23%. Tunnel infection rates decreased with increasing time on peritoneal dialysis: 2.4 per year for patients on peritoneal dialysis less than 1 year, 0.8 per year for patients on dialysis 1 to 2 years, and 0.4 per year for patients on dialysis greater than 2 years (all different at P less than 0.01). Organisms were cultured in 109 tunnel infections: gram-positive cocci in 77 episodes (71%) [Staphylococcus aureus 57, 52%], and gram-negative bacilli in 24 episodes (22%). Tunnel infection rates were higher in diabetics than in nondiabetics (0.27 per year v 0.16 per year, respectively; P less than 0.001 by life-table analysis of time to first infection) and also higher in women than in men (0.23 per year v 0.17 per year, P less than 0.001). Tunnel infection rates were 0.35 per year for diabetic women, 0.20 per year for diabetic men, 0.18 per year for nondiabetic women, and 0.15 per year for nondiabetic men (groups different, P less than 0.001). Race and age were similar in patients with and without tunnel infections. Catheter loss was 80% when tunnel infection was associated with peritonitis and 40% when tunnel infection alone was present (P less than 0.001). We conclude that the risk of tunnel infection is highest early in the course of peritoneal dialysis and that diabetic women, for unclear reasons, are at the highest risk.

Nephrologists' reported attitudes about factors influencing recommendations to initiate or withdraw dialysis.

A nationwide survey of nephrologists was performed to learn which patient factors and characteristics of nephrology fellowship training they reported as influencing their decisions to start or stop dialysis. One hundred seventy-four of 482 responses were received. Most respondents were men in private practice living in large communities (41% in communities over 1,000,000 population). Most had completed a 2-yr fellowship (88%) at a medical school hospital (75%). Few (9%) received formal instruction in medical ethics during fellowship training, and only one quarter had informally discussed life-sustaining treatments during training. Neurological status was the most, and age the least, important patient factor reported to influence decisions to start or stop dialysis. No respondent demographic factors correlated with ranking of patient factors in decisions to initiate or forego dialysis. Family wishes and preexisting medical conditions were significantly more important considerations in initiating than in stopping dialysis. Insights about the factors practicing nephrologists reportedly weigh most heavily in making the difficult decisions to withhold or withdraw dialysis are provided by this study. Additional study of the actual practices of nephrologists in decisions to initiate or withdraw dialysis and the factors influencing those decisions are needed. Formal instruction in these and other ethical problems confronting nephrologists should perhaps be included in fellowship programs.

The utility of a structured evaluation of elderly patients for continuous peritoneal dialysis.

The elderly comprise an increasing proportion of chronic dialysis patients. Recruiting them for continuous peritoneal dialysis (CPD) would help CPD programs maintain a patient population. We retrospectively studied the ability of a prospective evaluation to predict success with CPD in elderly (age greater than 60 years) patients. PD nurses and a renal social worker assigned scores in 10 categories, which were then averaged to obtain an over-all evaluation score. Scores were from 1-5 with 1 = good, 5 = poor, and 3 = average. Thirty-four elderly patients began CPD during the study period. Evaluation scores were available for 28 of these patients before they began dialysis. Evaluation scores less than 3 predicted success with CPD (2.2 +/- 0.2 versus 3.2 +/- 0.4 in patients transferring to hemodialysis, p less than 0.02). Patient motivation and preference were the categories that predicted success with CPD. Elderly patients were more likely than younger patients (those less than 60 years of age) to decline CPD for social reasons (46% versus 4% respectively, p less than 0.001). Elderly patients required more CPD training time than young patients (4.9 +/- 0.7 days versus 3.3 +/- 0.8 days respectively, p less than 0.01). We conclude that a prospective assessment of elderly patients can predict success with CPD and provide information important to individual structuring of CPD training and follow-up.

Patient factors and the influence of nephrologists, social workers, and nurses on patient decisions to choose continuous peritoneal dialysis.

To determine which members of the health care team are viewed by ESRD patients as the most helpful in giving information and deciding on a dialysis modality, we surveyed 42 outpatients after they toured the dialysis facility. The tour included discussions with a social worker, PD and HD nurses, watching a videotape, and receipt of written materials. Nephrologists referred patients for tours. Multiple responses were accepted. Patients felt that social workers (70%) and nurses (71%) gave the most useful information. Fifty per cent of patients thought the nurse, 43% the social worker, 21% the nephrologist, and 21% family or friend most helpful in deciding on PD versus HD. Twenty-three patients chose PD, 16 chose in-center HD. Patients choosing PD were more likely to be white (20/29 versus 3/10, p less than 0.05) and employed (11/23 versus 3/16 choosing HD, p less than 0.10). Patients choosing PD were also better educated but this was not independent of race. No differences in gender, age, or the presence of diabetes were seen among those choosing PD versus HD. Social workers and nurses are more influential than nephrologists in helping patients select a dialysis modality. PD patient recruitment efforts should focus on social workers' and nurses' input.

Continuous cycling peritoneal dialysis is associated with lower rates of catheter infections than continuous ambulatory peritoneal dialysis.

Continuous cycling peritoneal dialysis (CCPD), unlike continuous ambulatory peritoneal dialysis (CAPD), provides freedom from daytime exchanges and is associated with lower rates of peritonitis. However, catheter infection (CI) rates have not been reported for CCPD. Previous data suggested that a CAPD disconnect system (Y-set) was associated with lower rates of CI. These results suggested that patients on CCPD, which is also a disconnect system, might also have low CI rates. We evaluated our CCPD patients for infection rates and compared them with two groups of matched control CAPD patients, one using a spike system and one a Y-set disconnect system to evaluate this hypothesis. The CCPD patients had the lowest rates of CIs (0.5 episodes per year or one episode every 25 months), followed by the CAPD patients using the Y-set (0.8 episodes per year or one episode every 14 months). CAPD patients using the spike system had the highest rates of CIs (1.2 episodes per year or one episode every 10 months). Peritonitis rates followed the same pattern among the patient groups: CCPD, 0.3 episodes per year; CAPD, Y-set 0.5 episodes per year; CAPD, spike system 1.3 episodes per year. Our data suggest that disconnect systems, such as the CAPD Y-set and CCPD, reduce CIs, as well as peritonitis.

Gram-negative arthritis with a simultaneous urinary tract infection in a renal transplant recipient.

Infections are common causes of morbidity in the renal transplant population, but infectious arthritis is rarely encountered. Gram-negative joint infections in the nontransplant population are often associated with simultaneous urinary tract infections. We report a case of Escherichia coli monoarthritis and a concomitant urinary tract infection in a renal transplant recipient and consider the possible predisposing factors for the infection.

Dialysis patients' attitudes about cardiopulmonary resuscitation and stopping dialysis.

Dialysis patients are a unique population because of their chronic dependence on complex medical technology. Furthermore, their illness forces them to make critical decisions about medical care (mode of dialysis, renal transplantation, withdrawal from dialysis). The reasons dialysis patients discontinue therapy are not well understood, nor is it known whether they view dialysis therapy differently from other life-support interventions. We asked four groups of patients - in-center hemodialysis (HD), peritoneal dialysis (PD), renal transplant, and ambulatory elderly - questions about their wishes for (1) medical information, (2) participation in medical decision-making, (3) life-supporting therapy including cardiopulmonary resuscitation (CPR) and ventilatory support, and (4) stopping dialysis at the time of the study and in certain hypothetical situations. All groups wanted information and involvement in making medical decisions. Most patients desired CPR (96% of renal transplant, 76% of HD, 63% of PD, 82% of elderly), but PD patients chose CPR less often in all circumstances (at study, p = 0.004; in coma, p = 0.004; in permanent coma, p = 0.04), and they were less willing to undergo chronic ventilation (p = 0.001). PD patients were more likely to stop dialysis (p = 0.02) in coma than were HD patients. PD patients attended religious services more frequently and were less comfortable with machines, but these differences did not correlate with their decisions about life-support therapy. Dialysis patients have rarely considered stopping dialysis; they are similar to ambulatory elderly patients with regard to decisions about CPR and desire for involvement in medical decision-making. PD patients are a distinct subgroup worthy of further study.