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Biomedical subjects

B Piraino

Publications and source records attributed to B Piraino.

At least 19 recordsLinked to original sources
PubMed1999

Tolerance of large exchange volumes by peritoneal dialysis patients.

Improving clearances on peritoneal dialysis involves either more exchanges, greater fill volume, or both. An increase in the number of exchanges is inconvenient, resulting in noncompliance. Therefore, the best option is to increase the exchange volumes; however, patients are often reluctant for fear of discomfort. We tested the tolerance of 20 patients blinded to randomly sequenced volumes of 2, 2.5, and 3 L, performed incenter by the dialysis nurse. Each patient underwent one to three exchanges with each volume. At the end of a 4-hour dwell, the patient scored discomfort and estimated the infused volume. Only one study exchange was performed each day; the rest of the time, the patient continued his or her usual prescription. Fifteen of the patients (75%) were not able to identify the exchange volumes. Four of the five patients who determined the correct exchange volume for 67% to 78% of the exchanges (P < 0.04 compared with 33% expected by chance) had a body surface area greater than 1.75 m2. Of 123 exchanges, 84% were associated with no discomfort, 10% with mild discomfort, and 6% with moderate discomfort. Patients were not more likely to have discomfort with 3-L compared with lower fill volumes. Peritoneal clearances of creatinine (6.1 v 6.6 v 7.7 mL/min/1.73 m2) and urea nitrogen (7.3 v 8.6 v 9.5 mL/min) were progressively greater with increasing exchange volumes (P < 0.001). We conclude that the majority of small as well as large patients will tolerate 2.5- and 3-L exchange volumes. If encouraged to do so, many patients could tolerate greater exchange volumes than they are presently using. Exchange volumes should be readily increased as residual renal function declines.

Adult↗
PubMed1999

Hospitalization in peritoneal dialysis patients.

Hospitalization rates are declining more rapidly for peritoneal dialysis (PD) than for hemodialysis patients. This has been postulated to be caused in part by lower peritonitis rates. However, the causes of admission have not been reexamined in the setting of declining rates. We prospectively examined our hospitalization rates, causes of admission, and impact of peritonitis on hospitalization in adult PD patients at a single center over a 4-year period. There were 274 admissions in 168 patient-years for a rate of 1.6 admissions and 13.0 hospital days per patient-year. Rates were greater for men (1.8 v 1.5; P = 0.013), patients with diabetes (2.2 v 1.4, P < 0.001), and those with a higher peritoneal equilibration test result. Creatinine clearance and sex were independent predictors in a multivariate analysis. The most common causes for admission were cardiac disease (14.6%) and peritonitis (13.5%). Peritonitis accounted for 0.21 admissions and 2.0 hospital days per patient-year. Thirty percent of the incident patients were admitted during the first 90 days of dialysis. Admissions for dehydration and glucose abnormalities were more common in the first 90 days. Overall admission rates, as well as admission rates for peritonitis, did not change over time, although hospital days per year decreased. Those admitted for peritonitis had higher peritonitis rates, more time on PD, and were more likely to be black. Eighty-one percent of the admissions for peritonitis were caused by Staphylococcus aureus, Streptococcus spp, or gram-negative/fungal peritonitis. Patients with peritonitis caused by Staphylococcus epidermidis were less likely to be admitted than patients with peritonitis caused by other organisms. To conclude, peritonitis remains a common cause of hospitalization, despite low peritonitis rates. To decrease admissions for peritonitis, attention should be focused on preventing peritonitis caused by organisms other than S epidermidis.

Female↗
PubMed1998

Treatment of malnutrition with 1.1% amino acid peritoneal dialysis solution: results of a multicenter outpatient study.

A peritoneal dialysis (PD) solution containing 1.1% amino acids as the osmotic agent was evaluated in a 3-month randomized, prospective, open-label study in malnourished PD patients. Patients in the treatment group (DAA) received one or two exchanges daily with the amino acid solution, depending on tolerance, in place of glucose solutions. Controls (DD) received their usual therapy with glucose dialysate. Fifty-four DAA and 51 DD patients completed the study. In DAA, but not in DD patients, there was a significant increase at month 3 in serum insulin-like growth factor-1 (IGF-1) levels and significant decreases in serum potassium (all 3 months) and inorganic phosphorus levels (months 1 and 3), indicating a general anabolic response. Prealbumin and transferrin levels were significantly increased in DAA but not in DD patients at month 1, but the groups did not differ at months 2 and 3. In patients with baseline albumin levels less than 3.5 g/dL (bromcresol green [BCG] method), DAA patients showed increases in albumin, transferrin (months 1 and 2), and prealbumin levels (all 3 months) relative to baseline values, whereas these serum protein levels were unchanged in DD patients, although the changes from baseline did not differ between groups. In this subgroup, midarm muscle circumference (MAMC) did not change in DD or DAA patients. In patients with baseline albumin levels of 3.5 g/dL or greater, DD patients had decreases in albumin and total protein levels at all 3 months and in prealbumin levels at months 1 and 2, relative to baseline. In DAA patients, there were fewer changes in serum proteins. MAMC increased significantly from baseline in DAA but not in DD patients, although changes from baseline did not differ between DAA and DD groups. DAA patients showed no changes in peritoneal membrane transport characteristics. The results indicate that treatment with one or two exchanges daily of this amino acid-based PD solution is safe and provides nutritional benefit for malnourished PD patients.

Amino Acids↗
PubMed1998

Peritoneal urea and creatinine clearances in continuous peritoneal dialysis patients with different types of peritoneal solute transport.

We studied whether anuric subjects on continuous ambulatory peritoneal dialysis (CAPD) who achieve the target Kt/V urea of 2.0 weekly will also achieve the target normalized creatinine clearance (NCCr) of 60 liter/1.73 m2 weekly, and the reasons of discrepancy between the two clearances in anuric subjects, by analyzing 476 clearance studies performed in 309 CAPD patients within 12 months of the performance of a peritoneal equilibration test (PET). On the basis of the PET, peritoneal solute transport was classified as low (37 clearance studies), low-average (199 studies), high-average (186 studies) and high (54 studies). We found that weekly values of Kt/V urea in the low transport group (LTG) was 1.74 +/- 0.51, in the low-average transport group (LATG) was 1.66 +/- 0.41, in the high-average transport group (HATG) 1.68 +/- 0.41, and in the high transport group (HTG) 1.73 +/- 0.46 (NS, variance analysis). Weekly values for NCCr, liter/1.73 m2 were: LTG, 37.8 +/- 9.0; LATG, 44.0 +/- 9.2; HATG, 49.2 +/- 10.0; HTG 56.8 +/- 13.3 (P < 0.0001). The ratios of raw (not-normalized) peritoneal creatinine clearance to peritoneal urea clearance were: LTG, 0.65 +/- 0.14; LATG, 0.76 +/- 0.09; HATG, 0.84 +/- 0.09; HTG, 0.91 +/- 0.12 (P < 0.0001). Linear regression with Kt/V urea as x and NCcr as y revealed the following results: LTG, y = 19.486 + 10.500x, r = 0.591 [if x = 2.0, y = 15.004 + confidence interval (95% CI) of y 25.3 to 55.7]; LATG, y = 15.0004 + 17.482x, r = 0.774 (if x = 2.0, y = 50.0, 95% CI of y 38.4 to 61.6); HATG, y = 15.285 + 20.162x, r = 0.829 (if x = 2.0, y = 55.6, 95% CI of y 44.4 to 66.8); HTG, y = 14.945 + 24.134x, r = 0.839 (if x = 2.0, y = 63.2, 95% CI of y 48.4 to 78.1). Peritoneal solute transport type has a major effect on peritoneal creatinine clearance, but an insignificant effect on peritoneal urea clearance. Consequently, the majority of anuric patients who achieve a weekly Kt/V urea of 2.0 will have a weekly NC cr lower than 60 liter/1.73 m2 and will require a Kt/V urea much higher than 2.0 to achieve the target NCcr of 60 liter/1.73 m2 weekly. The current targets of urea and creatinine clearance are not compatible in anuric patients on CAPD.

Adult↗
PubMed1998

Compliance in CAPD and CCPD patients as measured by supply inventories during home visits.

This study was performed to determine compliance with prescribed exchanges in continuous ambulatory peritoneal dialysis (CAPD) and continuous cycler peritoneal dialysis (CCPD) patients via a home supply inventory, to evaluate numerous other factors against this standard, and to compare compliant and noncompliant patient characteristics and outcomes. It was an open enrollment of patients with prospective follow-up of 49 CAPD and CCPD adult patients at a university dialysis center. Two home visits for dialysis solution inventories were conducted 1 to 3 months apart. The number of exchanges actually performed (based on the inventory and deliveries) divided by the number of exchanges prescribed determined the percent compliance. Patient self-evaluation of compliance, attitudes about compliance and medical care, Derogatis Affects Balance Sheet (DABS) (a validated tool of affects balance), staff evaluations, patient demographics, hospitalizations, dialysis adequacy (measured to predicted creatinine ratio) and patient outcomes were evaluated against compliance with prescribed exchanges. Thirty-five percent of the patients were found to be noncompliant with prescribed exchanges based on the supply inventory, performing only 74% of exchanges. Compliant and noncompliant patients were not different by age, race, gender, peritoneal dialysis (PD) time, number of comorbid conditions, nor incidence of diabetes. The affects balance score from the DABS test was a poor predictor of compliance, as were staff evaluations. Delivered dialysis, adjusted for percentage of compliance, was significantly lower in noncompliant than in compliant patients by weekly Kt/V (2.2 v 1.74, P < 0.003), Ccreatinine L/week/1.73m2 (69 v 58, P = 0.05), as was normalized protein nitrogen appearance rates (nPNA), g/kg/day (0.89 v 0.70, P = 0.001). Technique survival was significantly lower (P < 0.05) in noncompliant patients. Twenty-nine percent of the noncompliant patients transferred to hemodialysis for uremia compared with 6% of compliant patients, P = .04, with a mean follow-up time of 1 year per patient. Patient survival did not differ in the two groups. Peritonitis rates were higher in noncompliant than compliant patients (1.03/yr v 0.66/yr, P < 0.03), as were days hospitalized (908 per 100 patient-years v 1,016 per 100 patient-years, P < 0.04). Noncompliance with PD exchanges is significantly common in CAPD and CCPD patients. It occurs in one third of the patients at our center and contributes significantly to technique failure, inadequate dialysis, and an increased risk of both peritonitis and hospitalized days. Home visits to conduct supply inventories provide an excellent method of monitoring compliance.

Attitude to Health↗
PubMed1997

Estimating the daily dialysate drain volume required in CAPD for a target peritoneal creatinine clearance by body water and peritoneal transport characteristics.

Stepwise logistic regression performed in 324 clearance studies in 194 patients identified daily drain volume normalized by body water (DV/V) and peritoneal solute transport type as the predictors of peritoneal creatinine clearance (CCrp) in continuous ambulatory peritoneal dialysis (CAPD). Solution of the regression model for DV/V provided DV/V values predicted to provide a desired CCrp at different probabilities. The ability of the predicted DV/V to detect desired CCrp values was tested in a new set of 359 clearance studies in 217 CAPD patients who had a peritoneal equilibration test within 12 months of the clearance study. No patient with low transport had a CCrp exceeding 54 L/1.73 m2 weekly. The following DV/V values detected CCr > or = 54 L/1.73 m2 weekly with a probability of at least 80%: for low-average transport, 0.406 L/L per 24 hours; for high-average transport, 0.339 L/L per 24 hours; for high transport, 0.241 L/L per 24 hours. Corresponding DV/V values for a CCrp of 60 L/1.73 m2 weekly were as follows: for high-average transport, 0.351 L/L per 24 hours; for high transport, 0.271 L/L per 24 hours. For high-average transport, maximal body surface area (BSA) estimates allowing a CCrp of 60 L/1.73 m2 weekly at a CAPD schedule of four daily exchanges with 3-L exchange volume and 1.5 L/24 hour ultrafiltration volume, and with the specified DV/V values were 2.03 m2 in women and 1.77 m2 in men. Corresponding BSA estimates for high peritoneal solute transport were 2.58 m2 in women and 2.21 m2 in men. The delivered dose of CAPD, expressed as DV/V, required to achieve a target CCrp can be calculated from multivariate statistical models taking into account the peritoneal solute transport type. Multiplication of the required DV/V by V provides an estimate of the required daily exchange volume. Maximal BSA estimates allowing a target CCrp can be calculated for each gender and peritoneal solute transport type.

Biological Transport↗
PubMed1996

A randomized trial of Staphylococcus aureus prophylaxis in peritoneal dialysis patients: mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin.

The objective of this study was to compare prophylaxis for Staphylococcus aureus infections in peritoneal dialysis patients using 600 mg cyclic oral rifampin for 5 days every 3 months versus mupirocin calcium ointment 2% applied daily to the exit site. The study design was a prospective randomized trial, controlling for S aureus nasal carriage. Eighty-two continuous ambulatory and continuous cyclic peritoneal dialysis patients (54% male, 71 % white, 34% insulin-dependent, mean prestudy time on peritoneal dialysis 1.2 years) were randomly assigned to cyclic rifampin (n = 41 patients) or daily exit site mupirocin prophylaxis (n = 41 patients). Mean follow-up was 1 year. S aureus catheter infection rates were 0.13/yr with mupirocin and 0.15/yr with rifampin (P = NS). Both rates were significantly lower than the center's historical rate (the period between 1983 and 1992) of 0.46/yr prior to the study (P < 0.001). S aureus peritonitis rates were 0.04/yr with mupirocin and 0.02/yr with rifampin (P = NS), both significantly lower than the center's historical rate of 0.16/yr (P < 0.02). Catheter loss due to S aureus infections was 0.02/yr with mupirocin and 0/yr with rifampin (P = NS), both significantly lower than the center's historical rate of 0.12/yr (P < 0.001). There were no side effects in patients using mupirocin, but 12% were unable to continue rifampin due to side effects. We conclude that mupirocin ointment at the exit site and cyclic oral rifampin are equally effective in reducing S aureus catheter infections. In addition, rifampin or mupirocin significantly reduced S aureus peritonitis and catheter loss due to S aureus infections. Mupirocin at the exit site provides an excellent alternative prophylaxis for S aureus infections, particularly in patients who cannot tolerate oral rifampin therapy.

Administration, Cutaneous↗
PubMed1996

Peritonitis associated with exit site and tunnel infections.

We reviewed all episodes of peritonitis associated with exit site and/or tunnel infection (n = 87; rate, 0.1/yr; 13% of all peritonitis episodes) occurring from 1979 to 1995. The exit site or tunnel infection was diagnosed at the time or shortly after the patient presented with peritonitis in 66% of the episodes. In the other one third the exit site or tunnel infection was diagnosed a median of 40 days prior to the development of peritonitis. Staphylococcus aureus accounted for 52% of episodes. Pseudomonas aeruginosa was the next most common organism. In 63 (72%) of the episodes the catheter was removed to resolve the infection at a median of 8 days (range, 0 to 226 days) from the onset of peritonitis. Catheter removal after 5 days predominately for refractory peritonitis (n = 23; median time to removal, 8 days) or relapsing peritonitis (n = 11; median time to catheter removal, 103 days). Patients with relapsing peritonitis suffered two to four episodes prior to removal of the catheter. Patients with peritonitis associated with tunnel infection were more likely to lose their catheter than patients with peritonitis associated with exit site infection (86% v 58%), while Staphylococcus epidermidis infections were less likely to result in catheter loss compared with all other organisms (15% v 82%). After a protocol to reduce S aureus catheter infections was implemented in 1990, the rate of catheter-related peritonitis decreased from 0.14/yr to 0.05/yr due to a decrease in S aureus episodes. We conclude that peritonitis episodes associated with a tunnel infection infrequently resolve without catheter removal. Delayed catheter removal in such circumstances often results in refractory or relapsing peritonitis. Therefore, catheter removal should be done promptly. Antibiotic prophylaxis for S aureus can reduce catheter-related peritonitis.

Bacterial Infections↗
PubMed1996

Peritoneal catheter exit-site and tunnel infections.

Peritoneal catheter exit-site and tunnel infections may lead to peritonitis and catheter loss. Exit-site infections are diagnosed when there is pericatheter erythema and/or purulent drainage. Staphylococcus aureus is the most common cause of both exit-site and tunnel infections. S. aureus nasal carriage is an important risk factor for S. aureus catheter infections. Few other risk factors for catheter infections have been identified. Treatment of catheter infections consists of antibiotic therapy, often prolonged, as well as intensification of exit-site care. Refractory cases may resolve with revision of the tunnel and exit-site with removal of the superficial cuff, but some patients undergoing this procedure will develop peritonitis. Once peritonitis develops from a tunnel infection, the catheter should be replaced. Research on prevention of catheter infections has focused on three areas: antibiotic prophylaxis, exit-site care, and new catheter designs. Several antibiotic protocols, including intranasal mupirocin, cyclical oral rifampin, and exit-site mupirocin, are effective in decreasing S. aureus catheter infections and should be used more widely. New catheter designs may, in the future, prove to further diminish catheter infection and loss, but there are insufficient data at this time to show superiority of one catheter over another.

Catheters, Indwelling↗
PubMed1996

Peritonitis influences mortality in peritoneal dialysis patients.

Mortality remains high in peritoneal dialysis (PD) patients. Known risk factors for mortality include age, diabetes, race, initial albumin level, and cardiovascular disease. Peritonitis is reported to cause death in 1 to 6% of PD patients but has not been well studied as a risk factor for mortality. This study examined 516 adults with a total of 896 yr on PD at one center to determine if peritonitis influenced mortality. Time at risk began on Day 1 of training and ended at death, transplant, or 60 days after transfer to hemodialysis or intermittent peritoneal dialysis. The overall mortality rate was 17.4/100 patient yr. Survival was lower for whites, men, diabetic patients, and older patients. Independent risk factors for mortality (by Cox proportional hazards) were race, diabetes, increased age, and increased peritonitis rate. Use of the Y-set was not associated with decreased mortality. Peritonitis was a risk factor only in whites, nondiabetic patients, and those patients over the age of 60. For every 0.5/yr increase in the peritonitis rate, the risk of death increased 10% in whites, 11% in those patients who were over the age of 60, and 4% for nondiabetic patients. Mortality rates did not decrease over time (1979 to 1995), although peritonitis rates fell significantly (P < 0.001). Rates of Gram-negative and fungal peritonitis showed no trend over time. Peritonitis contributed to 25 of 158 (15.8%) of deaths. Gram-negative/fungal peritonitis accounted for 14 deaths (9.5% of all Gram-negative/fungal episodes) whereas Staphylococcus epidermidis accounted for only 1 death (0.5% of all S. epidermidis episodes) (P < 0.001). Cardiovascular disease was more common in those patients whose deaths were unrelated to peritonitis (P < 0.01), whereas an infectious cause was more common in those patients whose deaths were peritonitis-related (P < 0.001). In this study, peritonitis was a risk factor for death in whites, nondiabetic patients, and older patients. However, the Y-set did not improve survival, perhaps because it does not decrease Gram-negative/fungal peritonitis. To have an impact on survival, efforts are needed to reduce the peritonitis that results from these more serious pathogens.

Adult↗
PubMed1996

Exit-site care.

Explore the source record for details and available documents.

Bacterial Infections↗
PubMed1996

Recommendations for dietary protein intake in CAPD patients.

Protein malnutrition occurs in 41%-42% of peritoneal dialysis (PD) patients, indicating that the current intake of protein is inadequate in many patients. With an intake of protein > or = 1 g/kg/day, most continuous ambulatory peritoneal dialysis (CAPD) patients are in positive or neutral nitrogen balance, while with an intake below this there is considerable risk of negative nitrogen balance. Most CAPD patients are prescribed a diet containing 1.2 g/kg/ day protein or higher, yet the majority of patients have an intake lower than this. Several factors are associated with inadequate protein intake including older age, comorbidity, and loss of residual renal function when the dialysis regimen is inadequate. A minimum weekly Kt/V of 2.0 is needed to achieve a protein intake of 0.9-1.0 g/kg/day. Patients with peritonitis and a permeable membrane have increased losses of protein via the dialysate, and so are at risk for protein malnutrition. To prevent and treat protein malnutrition, routine assessment of both nutritional status and dialysis adequacy are needed. Patients with an adequate clearance (weekly Kt/V of 2.0 or higher, creatinine clearance of 60 L/week/1.73 m2), who are eating 1 g/kg/day and have no markers of malnutrition, including a normal serum albumin, require no intervention. Protein supplements can be prescribed to increase the protein ingestion to 1.2 g/kg/day or more, if the serum albumin is low, or if the patient is clinically malnourished with weight loss and decreased muscle mass. Gastro-paresis and esophagitis, common in PD patients, can be treated. If supplements, dietary counseling, and adequate dialysis regimen do not result in improvement of nutritional status, amino acid dialysate may be beneficial. One to two exchanges per day using amino acid dialysate converts the nitrogen balance from neutral to positive in malnourished CAPD patients. To use amino acid dialysate successfully, the physician must be sure that the clearance is adequate as the serum urea nitrogen rises; inadequate dialysis can result in uremia and decreased intake.

Adult↗
PubMed1995

Research directions in peritoneal dialysis infections.

There are many promising areas of research on peritoneal dialysis related infections. Improvements in connection technology, especially the Y set and CCPD, have led to a decrease in the rate of peritonitis due to Staphylococcus epidermidis. The search to find a more biocompatible dialysate that is less immunocompromising is underway; clinical trials examining peritonitis rates with these new formulations remain to be performed. Considerable progress has been made in elucidating peritonitis related to catheter infection, especially that due to Staphylococcus aureus. Nasal carriage has been identified as a risk factor for subsequent infections. Several prophylactic antibiotic approaches including rifampin, trimethoprim/sulfamethoxazole and mupirocin have shown promise in reducing these infections. Innovative catheter designs that decrease the risk of bacterial colonization are another investigative approach. The timing of both catheter removal and replacement for infection is controversial and requires further study. Lastly, much remains to be learned about peritonitis from an enteric source.

Anti-Bacterial Agents↗
PubMed1995

Effect of increasing exchange volume or frequency on CAPD efficiency.

We evaluated the effect of increasing the volume of all exchanges (group A), increasing exchange frequency (group B), or increasing nocturnal exchange volume alone (group C) on dialysis urea and creatinine clearances (DUrCl and DCrCl, respectively) and on KT/V in 20 continuous ambulatory peritoneal dialysis (CAPD) patients (25 maneuvers in 20 patients). The average duration of the maneuver was 4.5 +/- 2.1 months. In group A, a significant increase occurred in DCrCl and DUrCl. Residual renal function (RRF) decreased by an average of 0.5 mL/min (not significant, NS). In group B, DUrCl increased by 19% (NS). RRF decreased significantly from 2.5 +/- 1.0 mL/min to 1.0 +/- 0.6 mL/min. In group C no changes were noted in dialysate clearances or RRF. In all groups KT/V was maintained regardless of the maneuver employed and despite the changes in dialysis clearance observed in groups A and B. This stability is probably related to the significant decline in RRF for the group as a whole during the observation period. KT/V can be maintained as RRF declines with either increases in dialysate volume or exchange frequency. However, efforts to increase KT/V to higher mandated values will probably require changes in both dialysate volume and frequency.

Creatinine↗