Outcome of grafts with long-lasting delayed function after renal transplantation.

To assess the impact of long-lasting acute renal failure after renal transplantation on late graft prognosis, we compared the risk factors and outcome in renal allografts with delayed function for >3 weeks after renal transplantation (long-lasting delayed graft function [LLDGF]) (group A, n=64), and in four control groups: group B, initially functioning grafts (n=322); group C, grafts with delayed function for <2 weeks after transplantation (n=110); group D, grafts with delayed function for 14 to 20 days after transplantation (n=57); and group E, never-functioning grafts (n=88). Donor asystolia or instability, stroke as a cause of donor's death, and prolonged cold ischemia and vascular surgical times were some predictors of LLDGF. Overlap was important, but 43% of patients of group A, 15% of group B, 25% of group C, 31% of group D, and 40% of group E (P<0.01) presented two or more risk factors for severe acute tubular necrosis after transplantation. Acute rejection and early complications were very frequent in group A. Also, patient survival was significantly decreased in group A, due to a higher incidence of infectious mortality. Graft survival was moderately (NS) decreased in group A. Serum creatinine was initially higher in patients of group A, but differences disappeared after the second year. However, late proteinuria was more frequent in group A, and there was also a trend for a higher prevalence of hypertension in this group. LLDGF cannot be reliably predicted at the time of renal transplantation. The main consequence of LLDGF is an excess mortality, while the impact on late graft function is less significant. Short-lasting delayed graft function does not seem to have a negative impact on the outcome of renal transplantation.

Ciprofloxacin in the treatment of gram-positive bacterial peritonitis in patients undergoing CAPD.

Fluoroquinolones may be a good alternative for the treatment of bacterial peritonitis in patients undergoing continuous ambulatory peritonitis dialysis (CAPD). To test their efficiency against Gram-positive bacteria, we treated with intraperitoneal (i.p.) ciprofloxac in 30 episodes of Gram-positive bacterial peritonitis without manifest tunnel infection of the peritoneal catheters. Treatment was sustained for 5 days, then orally for 10 further days. Clinical and bacteriological responses were satisfactory in 25 cases, but resolution of infection was slow in 5 cases of Staphylococcus aureus. The minimal inhibitory and bactericidal concentrations were 0.0625-0.50 and 0.125-1.0 micrograms/mL respectively, lower than the plasma and dialysate concentrations of the drug. Side effects were negligible. We conclude that ciprofloxacin provides a good therapeutic alternative to more widely used antibiotics for the empirical treatment of peritonitis in patients undergoing CAPD. However, combinations of antibiotics may be necessary, in Staphylococcus aureus peritonitis.

Renal transplantation in patients undergoing chronic peritoneal dialysis.

OBJECTIVE: To review the outcome of renal transplantation in a group of patients treated with chronic peritoneal dialysis and to compare the results with those of a matched population on hemodialysis. DESIGN: Retrospective study. SETTING: Tertiary, institutional hospital, administering to a population of two million, with 100 patients on peritoneal dialysis. Six hundred and sixty renal transplantations were performed by the end of 1993. PATIENTS: Fifty-six patients on chronic peritoneal dialysis who received 58 cadaveric renal allografts were compared to 58 patients on hemodialysis who received a graft from the same donor (n = 39), or the transplant next to the one performed to the corresponding patient on peritoneal dialysis (n = 19). RESULTS: Patients on peritoneal dialysis showed a lower rate of delayed graft function (24.1 vs 50%, p < 0.05) and a similar incidence of acute rejection than patients on hemodialysis. Also, peritoneal dialysis patients received less supplementary immunosuppression, suffered a lower incidence of late infections (0.93 vs 0.58 episodes/patient), and had a similar incidence of dialysis-related complications (0.25 vs 0.20 episodes/patient). CONCLUSIONS: Patients on peritoneal dialysis do well after renal transplantation. The incidence of some complications, particularly delayed graft function, is lower than in patients on hemodialysis, while the incidence of dialysis-associated complications is similar in both groups.

Treatment of peritonitis in CAPD with ciprofloxacin: long-term experience.

We present the long-term results of a protocol of empirical monotherapy of continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis with ciprofloxacin. One hundred and fifteen episodes of peritonitis were studied. The treatment protocol included 5 days of intraperitoneal (IP) administration of the drug, followed by 10 days of oral therapy. A good clinical response was obtained in 83% of the cases, while treatment failure was observed in 4% and relapse in 7%. A decrease in the sensitivity to ciprofloxacin of the peritonitis agents was observed in the study, with Staphylococcus spp. in particular. Three episodes of peritonitis due to bacteria resistant in vitro to ciprofloxacin responded to the treatment protocol. Ciprofloxacin attained good plasma levels both after oral and IP administration. However, dialysate levels were poor after oral administration. The most frequent side effect was gastric intolerance to oral ciprofloxacin. Two patients experienced severe adverse reactions to the drug. Ciprofloxacin may be a good choice for empirical monotherapy of CAPD-related peritonitis. However, the emergence of bacterial resistances must be carefully monitored. The drug should be administered intraperitoneally, at least to induce remission of the infection. Side effects are not frequent, but ciprofloxacin should not be considered an innocuous drug.

Treatment of Staphylococcus aureus nasal carriers in CAPD with mupirocin.

We have studied the efficacy of topical Mupirocin for elimination of Staphylococcus aureus (Staph. aureus) nasal carriage in CAPD patients. Staph. aureus nasal carriers in our CAPD program were randomized to one of two groups: Group 1, treated with Mupirocin, and Group 2, treated with neomycin sulphate nasal ointment. The prevalence of Staph. aureus nasal colonization was 44% for patients (24/54) and 17% for dialysis partners (5/29). Group 1 included 11 patients and 1 partner, and Group 2, 8 patients and 2 partners. In Group 1, the eradication rate was 100%, and the recolonization rate was 0, 8, 41, 55 and 66% at 1, 2, 3, 6 and 10 months. In Group 2, the eradication rate was 40%, with a recolonization rate of 0.25 and 75% at 1, 2 and 3 months. Re-treatment with mupirocin was successful in 66% of the cases, compared to 20% for neomycin. The MIC90 of mupirocin for Staph. aureus was 0.5 mcg/mL, with an increase to 4 mcg/mL towards the end of the study. During the study period, there was a very low incidence of Staph. aureus peritonitis or catheter-related infections in patients treated with mupirocin. Secondary effects of mupirocin were negligible. Mupirocin is more effective than neomycin sulphate for the elimination of Staph. aureus nasal colonization in patients undergoing CAPD. Periodic re-treatment is frequently necessary, given the significant recolonization rate.

Renal allograft rupture: diagnostic role of ultrasound.

To evaluate the diagnostic role of ultrasound in spontaneous renal allograft rupture we reviewed 18 cases observed in our centre in 10 years. Ultrasound studies were performed immediately before surgery in 15 cases. Renal allograft rupture occurred during the first 3 weeks after transplantation in 17 cases (94%). Clinical findings were consistent with previous reports. The diagnosis was confirmed by surgical exploration in 17 cases, and by necropsy in the remaining one. Nine patients were treated by corsetage and eight by graft nephrectomy, while one patient died before surgery. Acute rejection was present in nine cases, and severe acute tubular necrosis in five; no renal tissue was available for histological study in four patients. On ultrasound examination, perirenal haematoma was the most frequent finding, while subcapsular/intrarenal haematoma or findings suggesting rejection or urinary tract obstruction were less frequently observed. In six cases, disruption of the white linear echoes of the capsule of the graft could be seen; this finding has not been described previously. Ultrasound has a definite role in presurgical evaluation of suspected renal transplant rupture.

Treatment of Staphylococcus aureus nasal carriers in continuous ambulatory peritoneal dialysis with mupirocin: long-term results.

We present the clinical results of a prospective protocol of the treatment of Staphylococcus aureus nasal carriers (SANCs) in our continuous ambulatory peritoneal dialysis unit with mupirocin (Bactroban, SmithKline Beecham Pharmaceuticals, Philadelphia, PA). We monitored the incidence of peritonitis and catheter exit-site infection, the rate of infection-related catheter loss, and the degree of association between SANC state and S aureus infection. The study group included 94 patients with a follow-up of 1,097 patient-months (phase B). The same information was retrospectively collected among 74 continuous ambulatory peritoneal dialysis patients treated during the 24 months preceding the study period (follow-up of 1,043 patient-months) (phase A). S aureus nasal carriage was observed in 47.5% of the patients. Mupirocin was very effective in eradicating S aureus from the nares, but most patients required periodic retreatment. The incidence of S aureus peritonitis decreased from 1 episode/58 patient-months in phase A to 1 episode/548 patient-months in phase B, and the incidence of exit-site infection decreased from one episode/55 patient-months in phase A to 1 episode/137 patient-months in phase B. However, there was a simultaneous increase in the incidence of infections by other gram-positive and -negative bacteria. The rate of catheter loss after peritonitis (P = not significant) or exit-site infection (P < 0.05) tended to decrease from phase A to phase B. Seventy-seven percent of the peritonitis infections and 74% of the exit-site infections by S aureus occurred in SANCs.(ABSTRACT TRUNCATED AT 250 WORDS)