Chronic renal failure, diabetes mellitus type-II, and gestation: an overwhelming combination.

This case report highlights on a child-bearer with chronic renal failure and diabetes mellitus type-II. Chronic renal failure (CRF) with diabetes mellitus (DM) type I in gestation is a rare case of a high-risk pregnancy. What is of significance though in this gestation, is that conception was achieved with the patient treated by a dialysis program. Furthermore, neither hypertension nor intrauterine growth restriction (IUGR) were detected and the patient was normotensive throughout gestation with no clinical signs of anemia. Strict and frequent application of the dialysis programs eradicates the uremic intrauterine environment, reduces the amniotic fluid volume, eliminates the chances of uterine rupture, leads to a longer gestation, increases the newborn's birth weight, and offers an optimal fetal survival rate; this is of note mainly in patients with cesarean sections reported in their medical history. To eliminate the complications of a premature delivery, the present authors had to find the right time point to give birth to this baby taking into account lung maturity, amniotic fluid volume, and preservation of the anatomical uterine integrity.

Brucellosis in dialysis patients. Does it exist?

BACKGROUND: Brucellosis is a zoonotic disease transmittable to humans. It is diagnosed either by isolation of Brucella organism in culture of blood or other sample types (e.g., bone marrow or liver biopsy specimens), or by a combination of serological tests and clinical findings. Dialysis patients constitute a special population group with an impaired autoimmune system and a propensity to develop infections, such as brucellosis. This paper presents the high incidence of brucellosis in our dialysis patients during last year, while there was not any zoonotic infection recorded in the previous at least 5 year period. METHODS-RESULTS: This is a retrospective study including 8 dialysis patients, undergoing renal replacement therapies (5 patients were on hemodialysis (HD) and 3 on peritoneal dialysis (PD)), who out of a total of 124 patients developed brucellosis, during the last year. Four patients were male and four female and their mean age was 67 +/- 9 years. Clinical presentation of Brucellosis infection was mild with low-grade fever and symptoms of influenza. All patients were living in places where animal brucellosis was prevalent. Infection was diagnosed on the basis of clinical symptoms and signs and with polymerase chain reaction (PCR) analysis of peripheral blood. The affected patients had consumed fresh unpasteurized milk and cheese and were treated with oral doxycycline and oral rifampicin for 6 weeks. All patients are in follow up for at least 1 year, during which there were no relapses. CONCLUSIONS: Brucellosis is a zoonotic disease that can occur in dialysis patients who are susceptible to infection under certain conditions. Our brucellosis patients lived in agricultural and veterinary areas and had consumed unpasteurized milk and cheese and insufficiently cooked meat derived from infected animals.

A tumor-like manifestation of extrapulmonary tuberculosis in a hemodialysis patient.

Though pulmonary tuberculosis (TBC) remains the commonest clinical presentation, extrapulmonary TBC is an increasingly important clinical problem. Among the extrapulmonary sites, primary liver tuberculosis seems to be an extremely rare location. Fewer than 100 cases of TBC hepatic abscesses have been reported whereas most of them have been originated from other sites, usually the lung and the gastrointestinal track. Therefore, in the absence of any particular symptom this infrequent location may lead to a delayed or missing diagnosis. The present study reports the difficulties in early diagnosis of an extrapulmonary TBC case, as it happened to a 53-year-old man with diabetic nephropathy who started on regular hemodialysis for 5 months. In such "atypical presentations" the clinicians should bear in their mind the possibility of the TBC occurrence, which usually responds well to the conventional antituberculous therapy.

The alteration of dialysate cancer antigen 125 concentration under a biocompatible bicarbonate peritoneal dialysis solution and the preservation of the mesothelial cell viability.

BACKGROUND: The importance to maintain the peritoneal membrane integrity for peritoneal dialysis (PD) patients by using biocompatible solutions (with low or no glucose as osmotic factor and low in glucose degradation products-GDPs, without lactate as a buffer and with normal pH) becomes progressively more evident. The aim of the present study was to investigate the clinical effects of a novel bicarbonate-based biocompatible PD fluid, evaluating the alteration in the concentrations of dialysate marker CA125, a glucoprotein indicator of mesothelial cell mass. PATIENTS AND METHODS; This is a single-center, prospective cohort study of 12 stable CAPD patients (4 women, 8 men), mean age 71.3 +/- of 6.01 years, mean PD duration 31.9 +/- 21.33 months, treated with the usual conventional PD solutions (with increased GDPs, low pH, and lactate as a buffer system). After a six-month period, the patients changed for the next six-month period into bicarbonate PD solutions (BicaVera, Fresenius), after which they returned into their previous schema of conventional solutions for another six months. The dialysate marker of CA125 was repeatedly estimated at the beginning of the study (T0), after six months phase with the bicarbonate solutions (T6), and at the end of study (T12), after the second six-month use of the conventional PD solutions. All the samples were taken at the end of a four-hour dwell of an exchange with PD solution 2.5% glucose. RESULTS: The dialysate mean value of CA125 at the beginning of the study (Td0-with conventional PD solutions) was 15.07 +/- 5.72U/mL. After six months with bicarbonate PD solutions, the mean CA125 value increased to 111.97 +/- 66.21U/mL, while the mean values dropped again to 22.72 +/- 16.06 U/mL at the end of the study, after the patients' return for another six months to the conventional solutions use. There was a statistically significant difference between the mean CA125 levels at the beginning (Td0) and the middle of the study (Td6; p = 0.00079) as well as between the mean levels of CA125 in the middle (Td6) and at the end of the study (Td12; p = 0.0014). In contrast, comparing the mean dialysate values of CA125 at the beginning (Td0) and at the end of the study (Td12), no statistically significant difference was revealed (p = 0.13). CONCLUSIONS: For the use of the bicarbonate-based PD, more biocompatible solutions for six months produced a statistically significant increase in the dialysate concentration of the mesothelial cell mass indicator CA125. The decrease at the end of the study of CA125 mean value at a level similar with that observed at the beginning, after the six-month period of the conventional PD solutions, indicates that the clinical use of the new bicarbonate-based PD solutions may have an advantageous role in the preservation of peritoneal cell mass, maintaining also the integrity and longevity of the peritoneal membrane.

Urological management of indinavir-associated acute renal failure in HIV-positive patients.

INTRODUCTION: Indinavir, a protease inhibitor that is commonly used to treat HIV infection, may cause crystal formation within the renal tubules when urine pH is above 3.5. Crystallization in the urine may lead to intrarenal crystal deposition and acute renal failure (ARF). AIM: To establish the beneficial urological management of acute renal failure caused by indinavir treatment of HIV/AIDS patients. PATIENTS--METHODS: Five HIV positive patients (four men, one woman) with a mean age of 32 years (range 28-36 years) were referred to our Department of Urology from an AIDS outpatient Clinic, because of the development of postrenal acute renal failure with continuously elevated creatinine and urea plasma levels after indinavir therapy. Among the initial therapeutic maneuvers, indinavir administration was interrupted for 1 week while bilateral double-J ureteral stents were inserted in all the HIV/AIDS patients, during the first 24-72 h to secure upper-tract drainage. Concurrently urine has been acidified by oral administration of the amino acid L: -methionine and oral fluid intake was increased. RESULTS: All the patients responded well to the treatment and their renal function was effortlessly restored to normal within a few days. CONCLUSION: HIV-positive patients receiving indinavir therapy might be complicated by acute renal failure, mainly due to intrarenal crystal deposition (tubules) or urolithiasis (postrenal obstruction). This adverse effect may simply manage by the discontinuation of indinavir administration, urine acidification, as well as the possible early insertion of bilateral double-J ureteral stents.

Tuberculous spondylitis in patients with end-stage renal disease undergoing chronic hemodialysis therapy.

Tuberculosis of the spine is not rare in immunocompromised patients and particularly in those with end-stage renal disease (ESRD). Furthermore, the possible vascular compromise of the spinal cord in patients with diabetic nephropathy may result in symptoms of neurological involvement that could lead to deterioration and paralysis. We report a series of 4 patients with ESRD undergoing dialysis that developed tuberculous spondylitis of the thoracic spine. Diabetic nephropathy was the primary cause for chronic kidney disease in 2 patients; 3 of these patients were treated conservatively with anti-tuberculous medication and orthotic splints and were cured. The fourth patient with diabetes mellitus and clinically evident signs and symptoms of severe vascular insufficiency has additionally developed incomplete paraplegia. A complete sensory recovery and partial recovery of the hip flexors and abductors within 3 months occurred, following decompression of the spine and drainage of the abscess, in combination with long-term anti-tuberculous treatment and spinal orthosis.

Timely transfer of peritoneal dialysis patients to hemodialysis improves survival rates.

AIMS: The two main renal replacement therapies (RRT)--hemodialysis (HD) and peritoneal dialysis (PD)--have been considered to be antagonistic in most published studies on the clinical outcomes of dialysis patients. Recently, it has been suggested that the complementary use of both modalities as an integrated care (IC) strategy might improve the survival rate of end-stage renal disease patients. The aim of this study was to estimate the final clinical outcome of PD patients when they transfer to HD because of complications related to PD. MATERIALS AND METHODS: We retrospectively analyzed data from the following patients that started RRT during the last 10 years: 33 PD patients (IC group; age 55 +/- 15 years, mean +/- SD) who transferred to HD, 134 PD patients (PD group, age 64 +/- 11 years) who remained in PD, and 132 HD patients (HD group, age 48 +/- 16 years) who started and continued in HD. The main reasons for the transfer to HD were relapsed peritonitis and loss of ultrafiltration, while various comorbid risk factors were adjusted by Cox hazards regression model (age, presence of diabetes or/and cardiovascular disease, serum hemoglobin and albumin levels, as well as the modality per se). RESULTS: 3- and 5-year survival rates for the IC, PD and HD groups were 97% and 81%, 54% and 28%, and 92% and 83%, respectively. The 5-year survival rate was significantly higher in IC patients than in PD patients (p < 0.00001) but, was not different from that in HD patients. CONCLUSIONS: Our results show that the IC of dialysis patients undergoing RRT improves the survival of patients on PD if they are transferred to HD upon the appearance of PD related complications.

Peritoneal catheter exit-site infections: predisposing factors, prevention and treatment.

Catheter-related infections, exit-site-tunnel infections and peritonitis remain the Achilles heel of peritoneal dialysis. Although the overall incidence of peritoneal-dialysis-related infectious complications has been reduced since the introduction of the Y-set and double bag system, approximately one-fifth of peritonitis episodes are associated with catheter exit-site and tunnel infections. Since its development in 1968, the Tenckhoff catheter has become one of the most widely used peritoneal catheters, and many have proposed that a number of modifications have made it a better choice. Controversies concerning the effect on exit-site infections of catheter(s) with one or two cuffs, with straight, coiled, Swan-Neck, or other modifications led to the randomized controlled studies that are reviewed in this paper. Several studies have confirmed that mupirocin, applied at the exit-site as part of regular exit-site care, reduces the risk of S. aureus exit-site and tunnel infections. Recently, the emergence on a world-wide basis of mupirocin-resistant S. aureus (MuRSA) in peritoneal dialysis patients has brought this prophylactic strategy into question. However the low frequency of resistant organisms after four years of mupirocin prophylaxis suggests that we can continue its use with annual surveillance. Once established, exit-site infections may respond to appropriate treatment, but if not the only option may be catheter removal and replacement. Although peritonitis risk has decreased over the past decade, mainly due to improvements in connection technology, exit-site and tunnel infections have not. An exit-site infection that does not respond to treatment may lead to tunnel infection and to persistent peritonitis, which may require catheter removal and occasionally discontinuation of the peritoneal dialysis. Therefore it is important to be familiar with these factors that predispose to exit-site infection and to know how to prevent and to treat such infections. This review will discuss factors that predispose to catheter-related exit-site infections, techniques of exit-site care, and ways to prevent exit-site infection, with emphasis on S. aureus infections and their treatment.

Outcome for continuous ambulatory peritoneal dialysis patients is not predicted by peritoneal permeability characteristics.

For the present study, we investigated the peritoneal transport of fluid and solutes and the clinical outcomes of 44 continuous ambulatory peritoneal dialysis (CAPD) patients with various peritoneal transport characteristics. Based on 24-hour urine and dialysate collections and 4-hour dwell studies [peritoneal equilibration test (PET)], the patients were divided into two transport groups by dialysate-to-plasma ratio of creatinine at 240 minutes (D/PCr240). The groups consisted of 21 high transporters (D/P = 0.81; mean age: 63.9 +/- 8.2 years) and 23 patients of other transport types (D/P < 0.81; mean age: 67.1 +/- 7.3). Mean CAPD duration was 57.14 +/- 30.4 months and 39.14 +/- 30.4 months respectively (p = 0.07). Estimations were made of weight, body surface area (BSA), percent body water, plasma albumin (PA), Kt/Vurea, weekly creatinine clearance (TCCr), fluid removal, residual renal function, and normalized protein catabolic rate (nPCR). The results showed that high transporters had statistically significant, lower values for: (1) peritoneal fluid (p = 0.02); (2) estimated glomerular filtration rate (GFR: 0.5 +/- 0.77 mL/min vs 2.15 +/- 2.2 mL/min, p = 0.002); and (3) nPCR (0.66 +/- 0.16 g/kg/day vs 0.84 +/- 0.23 g/kg/day, p = 0.003). No statistically significant differences were observed with regard to the other parameters (BSA, PA, Kt/Vurea, TCCr). Cumulative survival rates at two and five years were 90% and 70% for all patients. No statistically significant difference was seen when comparing the survival curves of high transporters and patients of other transport types (p = 0.33, Cox's F-test). In conclusion, we saw no clear evidence that higher peritoneal permeability negatively influences clinical outcome. Other comorbid factors may be related in a more important way to the survival rate for CAPD patients.

The effectiveness of mupirocin preventing Staphylococcus aureus in catheter-related infections in peritoneal dialysis.

The objective of this study was to evaluate the effectiveness of mupirocin on Staphylococcus aureus with regard to peritoneal dialysis (PD)-catheter exit-site infections (ESI), tunnel infections (TI), and peritonitis episodes (PE). The study was performed on 42 continuous ambulatory peritoneal dialysis (CAPD) patients (group I) treated from April 1998 to July 1999. These patients were instructed to apply mupirocin daily at the catheter exit site as part of their exit-site care. The control was the same group's historical infection data. Results were also recorded for a second group of 16 patients (group II) with newly implanted PD catheters were also instructed to apply mupirocin at the exit site daily. During the control period (before daily mupirocin application), group I recorded 16 episodes of ESI (0.30 episodes per patient-year), 6 episodes of TI (0.11 episodes per patient-year), 15 episodes of PE (0.28 episodes per patient-year), and one case of catheter removal (0.019 episodes per patient-year) owing to S. aureus exit-site infection coexisting with peritonitis. The rate of S. aureus exit-site infection during this period was 0.11 episodes per patient-year; of S. aureus tunnel infection, 0.057 episodes per patient-year; and of S. aureus peritonitis, 0.076 episodes per patient-year. During the mupirocin period, infections and peritonitis owing to S. aureus dramatically decreased (p < 0.01 and p < 0.001 respectively). The rate of S. aureus exit-site infection was 0.02 episodes per patient-year, with no S. aureus tunnel infections, and no catheter removals owing to S. aureus peritonitis. Similarly, in group II, no episodes were recorded of any ESI, TI, or PE owing to S. aureus, although 4 episodes of ESI (0.37 episodes per patient-year, 2 with other gram-positive bacteria, and 2 with gram-negative bacteria) and 8 PEs (0.75 episodes per patient-year) were seen. We conclude that mupirocin application provides excellent prophylaxis for catheter-related infections owing to S. aureus, and that reduction of these infections may improve the long-term survival of patients on CAPD.

Evaluation of changes in serum and dialysate levels of cancer antigen 125 in stable continuous ambulatory peritoneal dialysis patients.

To estimate the relationship between changes in the concentration of cancer antigen 125 (CA125) and peritoneal membrane kinetics, the permeability characteristics of 44 continuous ambulatory peritoneal dialysis (CAPD) patients who had been treated with peritoneal dialysis for at least six months were prospectively evaluated. Twenty-seven males (age 66 +/- 6 years, duration of CAPD 35.5 +/- 29 months) and seventeen females (age 63.7 +/- 9 years, duration of CAPD 47.7 +/- 32 months) were evaluated. Peritoneal equilibration test (PET) data and Adequest (Baxter Healthcare Corporation, Deerfield, Illinois, U.S.A.) data were analyzed in all patients over a 12-month period, while CA125 levels were measured in blood and dialysate samples. No statistically significant correlations were seen between the patients' age, sex, or peritonitis incidence rates, and serum and dialysate levels of CA125. Dialysate-to-plasma ratio (D/P) of small solutes at 0 and 240 minutes also showed no statistical correlation. Statistical analysis revealed a statistically significant negative correlation (r = -0.33, p = 0.035) between dialysate CA125 and duration of CAPD. The statistically significant difference found between dialysate CA125 concentrations at 0 minutes and 240 minutes (2.32 +/- 1.3 U/mL vs 9.08 +/- 6.8 U/mL, p < 0.0001), means that CA125 concentration increases with longer dwell time. These results suggest that the duration of CAPD clearly affects dialysate CA125 concentrations. CA125 may therefore be used as a useful marker to evaluate the mesothelial cell mass in longitudinal follow-up.

Failure of icodextrin to provide adequate ultrafiltration in continuous ambulatory peritoneal dialysis patients.

Icodextrin, a starch-derived glucose polymer with an average molecular weight of 20,000 D, has been developed partly as a response to some of the disadvantages of dextrose. It has been suggested that icodextrin solutions are able to provide sustained ultrafiltration (UF) over long dwell times of 8-12 hours in continuous ambulatory peritoneal dialysis (CAPD). In this paper we describe three patients on CAPD: 2 males and 1 female aged 60, 67, and 58 years respectively, duration on CAPD 47, 60, and 15 months respectively. All of these patients, who were categorized as high transporters according to peritoneal equilibration test (PET) results, presented early signs of ultrafiltration loss with no evidence of peritoneal inflammation. Icodextrin solution was used in a single nightly exchange with 10-12 hours' dwell, for a period of 5-30 days. In all of these cases, icodextrin solution failed to provide adequate ultrafiltration and the patients returned to the previously used regime of five daily hypertonic exchanges of 3.86% glucose concentration. Although these negative results were not clearly explained, we report these three cases because they exemplify some limitations of icodextrin solution to provide adequate ultrafiltration, at least in a small number of CAPD patients.

The identification of bone mineral density in CAPD in comparison with HD patients.

Renal osteodystrophy is a virtually universal complication of chronic renal failure (CRF). Varying degrees of calcium-phosphate metabolism derangement and different types of skeletal damage are observed in CRF for many reasons while the use of dialysis for the management of end-stage renal failure further affects these complications. This study was designed to evaluate the bone mineral density (BMD) that is measured by dual-energy x-ray in three groups of patients: A, 10 patients on continuous ambulatory peritoneal dialysis (CAPD); B, 10 patients on hemodialysis (HD); and C, 10 predialytic patients with advanced CRF. All patients were matched for age, sex, duration of dialysis (> 3 years), and the use of phosphate binders. Biochemical (serum iPTH levels, SAP, Ca, P) and radiological bone studies were compared in the three groups. The majority of predialytic patients had BMD values within the normal range, while the BMD values in PD patients were higher (0.985 g/cm2) in comparison with HD patients (0.949 g/cm2). Some patients, especially in the HD population, showed an increase in BMD with time on dialysis. From all other comparisons, radiological signs of high turnover bone disease and osteopenia were the only variables that were correlated with BMD. All these findings suggest that dialysis affects the bone status and that CAPD patients have better bone mineral metabolism as shown mainly with the use of BMD measurements.

Treatment and prevention of relapses of CAPD Pseudomonas peritonitis.

Pseudomonas peritonitis in continuous ambulatory peritoneal dialysis (CAPD) can be difficult to eradicate, because it is frequently resistant to common antibiotics, inducing the loss of the peritoneal cavity in some cases. A total of 14 episodes of Pseudomonas peritonitis in 12 patients (6 male, 6 female) were treated with intraperitoneal (IP) administration of a combination of ceftazidime and tobramycin. All patients were hospitalized. The loading doses were 1000 mg/2 L of ceftazidime and 1.7 mg/kg of tobramycin, and the maintenance IP doses were 250 mg/2 L of ceftazidime and 16 mg/2 L of tobramycin. The therapy duration was 14 days. In 7 episodes (group A) no other antibiotic regimen was provided, while in the remaining 7 episodes (group B) therapy was continued with 500 mg b.i.d. of oral ciprofloxacin for the next 14 days. Pseudomonas species isolated in group A were P. alcaligenis (1), P. putida (1), P. maltophilia (1), R. cepacia (1), and unidentified (3). In group B the following Pseudomonas species were isolated: P. aeruginosa (4), P. diminuta (1), P. stutszeri (1), and unidentified (1). Recurrence of peritonitis was seen in 4 episodes of group A with 2 catheter removals, while all episodes were cured in group B. These results suggest that IP ceftazidime and tobramycin with the additional use of oral ciprofloxacin is successful in the treatment and prevention of relapses of Pseudomonas peritonitis.

Evaluation of CNS-function in CAPD patients using magnetoencephalography (MEG): comparison with hemodialysis patients.

In order to evaluate the CNS-function of uremic patients, the magnetic activity emitted from the brain of 20 pts (10 pts on CAPD and 10 on HD) was measured. MEG consisted of taking 32 consecutive records from the 32 equally spaced points chosen on the skull in uremic pts around our reference points T3, T4, P4, F3, F4 of the international 10-20 electrode placement point system. MEG data were converted using an AD-converter with sampling frequency 256 Hz and stored in a P/C. Our results showed significant differences between the two groups. In all HD pts there was abnormal magnetic brain activity with high spectral amplitudes (in the band 2-7 Hz) which was more prominent in pts in hemo for more than 4 years. The magnetic activity was within normal ranges in all CAPD pts. We conclude that: 1) There is high magnetic brain activity in HD pts, which in accordance with the EEG findings are signs of diffuse encephalopathy. 2) CAPD pts show a very low magnetic brain activity which must be interpreted as normal brain function, and 3) MEG can be useful in further measurement of adequacy of dialysis.

Treatment of CAPD peritonitis with clavulanate potentiated ticarcillin.

A total of 16 episodes of peritonitis in 14 patients (9 males, 5 females), were treated with Clavulanate potentiated ticarcillin (TC), a -lactamase stable parenteral penicillin. All the pts were hospitalized and received initial loading dose of 3.2 gr intraperitoneally (i.p.) in a 6-hour 1 L exchange, which was followed by four 1 L exchanges with 320 mg/LTC. The therapy was continued for ten days. The bacteria isolated were: Staph. epid. (4), Staph. aureus (2), Strept. viridans (1), Enterococcus (1), Klebsiella Pneum. (1), Serratia (1), Enterobacter (1), Pseudomonas species: stutszeri (2), cepacia (1), fluorescens (1), negative cultures (1). Recurrence of peritonitis was seen in three patients with Pseudomonas (stutszeri (2), fluorescens (1)) peritonitis, 10-16 days after cessation of therapy. No clinical or biological side effects were seen in any patient during and/or after the therapy. These results suggest that, i.p. monotherapy of TC is effective in the treatment of CAPD peritonitis, while in cases of Pseudomonas peritonitis more specific regimens should be used.