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Biomedical subjects

B Piraino

Publications and source records attributed to B Piraino.

At least 55 records · Page 3Linked to original sources
PubMed1993

Splenic infarct presenting as sterile peritonitis with peripheral embolic phenomena.

Two patients with end-stage renal disease from diabetes mellitus on peritoneal dialysis for 2 or more years developed sterile peritonitis secondary to splenic infarcts with associated peripheral embolic phenomena. The dialysate had WBC counts > 200/microL, of which 70% or more were polymorphonuclear cells, and RBC counts of 60/microL or less, although transient hemoperitoneum occurred in both patients. Extensive atherosclerotic vascular disease as well as hematologic abnormalities were also present in both patients. One patient had polycythemia due to decreased plasma volume. The other patient had evidence of dysfibrinogenemia. The patients responded well to anticoagulation with warfarin. When the warfarin was discontinued, recurrent emboli occurred in both patients. Splenic infarct should be included in the differential diagnosis of diabetic patients with atherosclerotic disease who present with sterile peritonitis that does not respond to antibiotic therapy, especially if hemoperitoneum occurs even transiently. The diagnosis can be confirmed with CT scan of the abdomen. Warfarin therapy is effective in preventing recurrent embolic phenomena, but may need to be continued indefinitely.

Adult↗
PubMed1993

Characteristics and outcome of peritoneal dialysate leaks and associated infections.

Much is known about leaks on continuous ambulatory peritoneal dialysis (CAPD), but little is known about peritoneal dialysis-related infection associated with leaks. All catheter infections and peritonitis associated with leaks in established CAPD/CCPD (continuous cyclic peritoneal dialysis) patients occurring between 1979 and 1 July, 1992 were reviewed. Seventy-nine leaks occurred in 66 patients involving 76 catheters. Prophylactic antibiotics were given for all leaks. Thirty-three (42%) of the leaks were associated with an infection, and 46 (58%) were not. Patient sex, age, race, insulin dependence, and renal transplant within 60 days of leak were not different among patients with infection-associated leaks and those with leaks without infection. The median time on peritoneal dialysis prior to the leak was shorter in patients without an associated infection than in those with an associated infection (1.9 vs 5.6 months, p = 0.03). More catheters were removed in the infection-associated group (17/33, 52% vs 11/43, 26%, p = 0.03). Infection preceded leaks by a median of 20 days in 22/33 and was followed by leaks in a median of 14 days in 11/33 leaks. More of the catheters with a preceding infection were removed (14/22, 64% vs 3/11, 27%, p = 0.05). Infections occurring after a leak were often polymicrobial (5/7 catheter infections and 2/4 peritonitis episodes), while those occurring before a leak were single-organism infections (21/22). Catheter infections and peritonitis followed by a leak often lead to catheter loss and probably indicate infection of the catheter's deep cuff. Infections following leaks often resolve and are likely secondary, rather than primary infections.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Calcium mass transfer with 10-hour dwell time using 1.25 versus 1.75 mmol/L calcium dialysate.

Dialysate containing 1.25 mmol/L calcium and 2.5 g/dL dextrose has been shown to have a negative calcium mass transfer (CMT) in a 4-hour exchange. Continuous ambulatory peritoneal dialysis (CAPD) patients usually perform three daytime exchanges that have short dwell times and one overnight exchange that dwells for 8-10 hours. Measurement of CMT with a 10-hour overnight CAPD exchange has not been done. Thirty-four CMT measurements were performed on 18 patients using 1.25 (n = 15) and 1.75 mmol/L (n = 19) calcium dialysate, both containing 2.5 g/dL dextrose, with a dwell time of 10 hours. The mean CMT values were -0.75 +/- 0.45 and 0.42 +/- 0.54 mmol/exchange for 1.25 and 1.75 mmol/L calcium dialysate, respectively (p < 0.001). The serum ionized calcium levels were similar in the two groups, 1.2 mmol/L. With multivariate analysis the CMT values had a negative correlation with drain volumes (r = -0.5, p = 0.0001) and serum-ionized calcium (r = -0.4, p = 0.002). In conclusion, the CMT of an overnight exchange using 2.5 g/dL dextrose is determined by the initial dialysate calcium, the ultrafiltration volume, and the serum-ionized calcium. An overnight dwell using 1.25 mmol/L calcium dialysate will contribute to negative calcium balance, allowing larger doses of oral calcium compounds to be prescribed.

Adult↗
PubMed1993

A randomized trial comparing 2.5 mEq/L calcium dialysate and calcitriol to 3.5 mEq/L calcium dialysate in patients on peritoneal dialysis.

Peritoneal dialysate containing 2.5 mEq/L of calcium has been used to prevent hypercalcemia when calcium-containing phosphate binders are given. However, worsening of hyperparathyroidism may result. Calcitriol used in conjunction with 2.5 mEq/L calcium dialysate is an attractive alternative, but has not been examined in a controlled trial. Eighteen patients were randomly assigned to either a control group (3.5 mEq/L calcium dialysate without calcitriol) or a study group (conversion to 2.5 mEq/L calcium dialysate with oral calcitriol, median dose 0.25 microgram/day). The initial mean serum calcium (9.9 vs 9.6 mg/dL), phosphate (5.4 vs 5.6 mg/dL), median n-terminal parathyroid hormone (PTH) levels (71 vs 55 pg/mL, normal < 25), and median 1,25 (OH)2 vitamin D levels (4 vs 5 pg/mL, normal 15-60 pg/mL) were not different in the two groups. After 8 weeks the serum calcium and phosphate were unchanged from baseline in both groups. The 9 patients who converted to 2.5 mEq/L calcium dialysate had an insignificant fall in the PTH level, not different from the control group. The median 1,25 (OH)2 vitamin D level rose from 4 to 23 pg/mL (p = 0.003) on calcitriol, but remained unchanged in the control group (5 pg/mL). The median doses of oral calcium (0.9 vs 1.1 g/day) and the frequency of serum calcium levels greater than 11 mg/dL (4/9 vs 3/9 patients, 10% vs 8% of all values) were similar in the study and control groups. Aluminum hydroxide was required intermittently for serum phosphate control in 3 patients on 2.5 mEq/L calcium dialysate and 4 on 3.5 mEq/L calcium dialysate.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed1993

Correlation of normalized protein catabolic rate to weekly creatinine clearance and KT/V in patients on peritoneal dialysis.

We collected data on 43 stable peritoneal dialysis patients (60 values), all of whom had residual renal function, to determine the dependency of normalized protein catabolic rate (PCRN) on residual renal function as well as dialysis adequacy. All patients were on a stable peritoneal dialysis regimen for at least 4 months (median 8 months, range 4-64 months) and were without peritonitis or other serious infections for at least 6 months prior to data collection. Dialysate creatinine clearance (Ccr) was obtained from 24-hour collections of dialysate. Residual renal function was calculated from the average of the urea and the creatinine clearance from 24-hour urine collections. The normalized protein catabolic rate was calculated using the Randerson method. Using linear regression analysis, PCRN correlated with total weekly Ccr (r = 0.7, p < 0.0005), KT/V urea (r = 0.5, p < 0.0005), and residual renal function (r = 0.6, p < 0.0005). All patients with residual renal function more than 40 L/week had a PCRN greater than 1.0 g/kg/day. To assure a PCRN of 1.0 g/kg/day in all patients, a weekly KT/V urea of 1.9 and/or a total weekly Ccr of 79 L was required. These results confirm the important role of residual renal function in dialysis adequacy and elucidates its contribution to the maintenance of the patient's protein intake.

Creatinine↗
PubMed1993

A comparison of peritoneal dialysis-related infections in short- and long-term peritoneal dialysis patients.

OBJECTIVE: We hypothesized that the infection rates and organisms would differ in long-term peritoneal dialysis (PD) patients versus those who died or transferred to hemodialysis during the first 4 years on PD. DESIGN: Data on PD-related infections and outcome were collected from 1979 to 1991 (prospectively since 1982). SETTING: The patients were followed at University and Veterans Administration dialysis centers. PATIENTS: All patients on continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) for 4 years or more (n = 43) were compared to those patients who died or transferred to hemodialysis prior to 4 years on PD (n = 213). MAIN OUTCOME MEASURES: Infection rates due to various microorganisms and reasons for transfer to hemodialysis were examined. RESULTS: Peritonitis rates were 1.2/year versus 0.8/year (p < 0.001) in patients on peritoneal dialysis less than 4 years compared to those on 4 years or more, respectively, a difference due to S. epidermidis (0.32/year vs 0.20/year, p = 0.0001) and gram-negative rods other than P. aeruginosa (0.15/year versus 0.06/year, p < 0.001). Exit-site infection rates were 1.2/year versus 0.7/y (p < 0.0001) in the patients on less than 4 years compared to those on 4 years or more, respectively, a difference in part due to S. aureus (0.45/year vs 0.3/year, p < 0.001) and other gram-positive organisms (0.28/year vs 0.10/year, p < 0.001). The rates of infections that were similar in the two groups were tunnel infections (0.2/year), P. aeruginosa infections, and S. aureus peritonitis (0.18/year vs 0.14/year, p = 0.09). S. aureus was the most common cause of exist-site and tunnel infections in both groups. Forty-two percent of the patients on PD 4 years or more subsequently transferred to hemodialysis, most often due to infections, especially S. aureus. CONCLUSIONS: Although infection rates are lower in patients on peritoneal dialysis 4 years or more, S. aureus and P. aeruginosa continue to account for a high proportion of the infections. Improvement in technique survival will require prevention of these infections.

Bacterial Infections↗
PubMed1993

Staphylococcus aureus peritonitis is associated with Staphylococcus aureus nasal carriage in peritoneal dialysis patients.

Although the definition of S. aureus nasal carriage in peritoneal dialysis patients is variable, carriage is often defined as 2 or more positive cultures for S. aureus. We investigated the relationship between S. aureus infections and nasal carriage (defined as 1 or more positive nose cultures) in 138 patients on peritoneal dialysis. By this definition, approximately 50% of the patients were carriers. The rates of S. aureus exit-site infection (0.28/year vs 0.43/year, p < 0.001) and peritonitis (0.08/year vs 0.20/year, p < 0.001) were lower in the noncarriers (patients with no positive nose cultures) than in those patients who had 1 or more positive nose cultures. Patients with only 1 positive nose culture had a similar S. aureus exit-site infection rate (0.31/year vs 0.28/year), but a higher peritonitis rate (0.24/year vs 0.08/year, p < 0.001) compared to those patients with no positive nose cultures. However, patients with 2 or more positive nose cultures were at increased risk for both S. aureus exit-site infections and peritonitis. This relationship held even when only patients with frequent nose cultures were included in the analysis. Thus patients with even 1 positive nose culture for S. aureus are at risk for S. aureus peritonitis and should not be classified as noncarriers.

Carrier State↗
PubMed1993

A comparison of peritoneal dialysis-related infections in black and white patients.

OBJECTIVE: To determine if black patients in our peritoneal dialysis (PD) program had higher rates of PD-related infections. The outcomes of black patients versus white patients were also reviewed. DESIGN: A review of prospectively collected patient demographic and PD-related infection data and outcomes, from 1979 to 1991. PATIENTS: The 68 black patients in our PD program were matched with white control patients for age, sex, insulin dependence, time on dialysis, and mode of dialysis (CAPD or CCPD). The infection, demographic, and outcome data from the two groups were compared. RESULTS: Black patients had higher peritonitis rates (1.10 vs 0.82 episodes/year, p = 0.001) and exit-site infection rates (1.13 vs 0.95 episodes/year, p = 0.02) than the white control patients. Tunnel infection rates were 0.21 episodes/year in both groups. S. epidermidis peritonitis was more common in black patients (48% of episodes vs 21% of episodes in whites, p = 0.005), and S. aureus peritonitis was more common in white patients (29% vs 11% in blacks, p = 0.005). The subset of black patients (n = 13) on a disconnect system (Y-set) had a peritonitis rate similar to their white controls on the Y-set (0.41 vs 0.74 episodes/year, p = 0.27). There were no episodes of S. epidermidis peritonitis in this subset of black patients. Black patients had fewer S. aureus exit-site infections than white patients (21% vs 41%, p = 0.005). Peritonitis was the leading cause of transfer to hemodialysis in the black patients but not in the white patients. CONCLUSION: The susceptibility to S. aureus and S. epidermidis infections differs in black and white patients on peritoneal dialysis for unclear reasons. Peritonitis rates in black patients can be reduced to that of white patients if a disconnect system is used.

Black People↗
PubMed1992

Polymicrobial peritonitis in patients on continuous peritoneal dialysis.

Little data are available about the characteristics, outcome, and risk factors for polymicrobial peritonitis in patients on continuous peritoneal dialysis. We therefore reviewed the 43 episodes of polymicrobial peritonitis that occurred in 39 of our patients over the 11.5 years of our program. Polymicrobial peritonitis represented 9% (43/492) of all peritonitis episodes. Only three episodes of polymicrobial peritonitis were associated with an enteric source. Sixteen percent (7/43) of the polymicrobial peritonitis episodes were associated with catheter infections. Staphylococcus aureus was one of the cultured organisms in 33% of the polymicrobial peritonitis episodes. Patients with polymicrobial peritonitis had higher rates of tunnel infection (0.28/yr v 0.18/yr) and overall peritonitis (1.23/yr v 0.81/yr) than patients with single-organism peritonitis. Black patients were more likely to have polymicrobial peritonitis (12/56 v 27/338 whites, chi 2 = 9.8, P less than 0.005). Patient age, gender, time on peritoneal dialysis, insulin dependence, and cause of end-stage renal disease had no influence on polymicrobial peritonitis. Significantly more catheters were removed for polymicrobial peritonitis than for single-organism peritonitis (17/42 v 89/420, chi 2 = 7.05, P less than 0.01), but in 60% of the episodes, the polymicrobial peritonitis was successfully treated without catheter removal. Polymicrobial peritonitis often occurs without gram-negative organisms and extension of catheter infection may be involved in some cases. For unclear reasons, black patients are at higher risk of polymicrobial peritonitis.

Bacteria↗
PubMed1992

Calcium mass transfer with dialysate containing 1.25 and 1.75 mmol/L calcium in peritoneal dialysis patients.

Studies with 1.75 mmol/L calcium dialysate have shown that patients gain calcium from dialysate. Thus, hypercalcemia, especially when calcium compounds are used for phosphate control, is a commonly seen complication. Dialysate with 1.25 mmol/L calcium has been available since 1989. Little is known about calcium mass transfer (CMT) with dialysate of this calcium concentration. CMT was measured in 20 stable adult peritoneal dialysis patients. Each CMT study consisted of a 2-L continuous ambulatory peritoneal dialysis (CAPD) exchange with a dwell time of 4 hours. CMT studies were performed using 1.25 and 1.75 mmol/L calcium dialysate with 1.5, 2.5, and 4.25 g/dL dextrose concentrations. CMT with 1.25 mmol/L calcium dialysate was compared to that with 1.75 mmol/L for each dextrose concentration. With a dextrose concentration of 1.5 g/dL, the mean CMT for 1.25 mmol/L calcium dialysate was -0.1 +/- 0.3 mmol versus 0.6 +/- 0.3 mmol for 1.75 mmol/L calcium dialysate (P < 0.0001). A dextrose concentration of 2.5 g/dL resulted in a mean CMT of -0.4 +/- 0.2 mmol for 1.25 mmol/L calcium versus 0.45 +/- 0.25 mmol for 1.75 mmol/L calcium (P < 0.0001). Using a dextrose concentration of 4.25 g/dL, the mean CMT was -0.7 +/- 0.25 mmol for 1.25 mmol/L calcium versus -0.05 +/- 0.35 mmol for 1.75 mmol/L calcium (P < 0.0001). Mean serum ionized calcium (SiCa) was between 1.15 and 1.20 mmol/L for all study groups. CMT inversely correlated with SiCa for each type of dialysate used. CMT was dependent on the concentrations of calcium and dextrose in the dialysate and the SiCa level at the time of the exchange.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

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)

Adult↗
PubMed1992

Alprazolam in end-stage renal disease. II. Pharmacodynamics.

The sensitivity to the psychomotor and memory effects of alprazolam was evaluated in 12 normal subjects and 12 dialysis patients (seven patients receiving hemodialysis and five patients receiving continuous ambulatory peritoneal dialysis). Subjects received a single oral dose of 0.5 mg alprazolam, 2 mg alprazolam, and placebo in a double-blind, placebo-controlled, balanced, three-way crossover study with a Latin square design. After administration of the test drug, blood was obtained for alprazolam concentration and protein-binding determinations, and psychomotor performance, memory, and sedation were assessed. The maximum psychomotor impairment corrected for free alprazolam concentration was 5.0%, 8.2%, and 10.1% per nanogram per milliliter in normal subjects, patients receiving hemodialysis, and patients receiving continuous ambulatory peritoneal dialysis, respectively (p less than 0.01), after administration of 2 mg alprazolam. Free alprazolam concentrations at which 50% of maximum effect is elicited for psychomotor impairment were 10, 7.40, and 5.31 ng/ml in normal subjects, patients receiving hemodialysis, and patients receiving continuous ambulatory peritoneal dialysis, respectively. The maximum memory impairment corrected for the maximum free alprazolam concentration was 4.4%, 7.2%, and 8.9% per nanogram per milliliter, respectively (p less than 0.09), after administration of 2 mg alprazolam. Thus our group of patients receiving dialysis showed enhanced sensitivity to some psychomotor and memory effects of alprazolam.

Adult↗
PubMed1992

Erythema: does it indicate infection in a peritoneal catheter exit site?

The definition of a peritoneal catheter exit site infection varies from one dialysis center to another. A review of abnormal appearing exit sites (n = 334 in 169 patients) from 1/83 to 3/91 was done to compare outcome in exit sites presenting with erythema (39, 12%) to those with drainage plus erythema (72, 22%) or drainage alone (223, 67%). Resolution of the abnormality occurred in 48% of those exit sites with drainage, 62% with erythema and drainage, and 79% with erythema alone (p < 0.005). S. aureus was present in 62% of the cultured exit sites which had erythema alone, 64% with erythema plus drainage, and 41% with drainage alone, while Gram negative rods were present in 13%, 12%, and 35%, respectively (p < 0.005). Twenty-three of the 39 exit sites with erythema were not initially treated with antibiotics; 87% resolved compared with 69% of those treated immediately with antibiotics (p = ns). Seven of the 8 erythematous exit sites that did not resolve progressed to tunnel infection and/or peritonitis and required catheter removal, despite the addition of antibiotics in the three initially untreated. Six of the 8 unresolved erythematous exit sites were due to S. aureus. These results indicate that, although drainage is the commonest exit site abnormality and has the worst prognosis, peri-catheter erythema is not always benign, representing an early sign of infection in some cases.

Catheterization↗
PubMed1992

Erythropoietin in pregnancies complicated by severe anemia of renal failure.

BACKGROUND: Recombinant human erythropoietin has been approved for treatment of the anemia of renal failure since 1989, yet data regarding the safety and efficacy of this drug in pregnancy are limited. We used recombinant human erythropoietin to treat the anemia of renal disease in three pregnant women. CASES: Nadir hematocrit values before initiation of erythropoietin were 19-23%. Erythropoietin, 50-160 U/kg/week subcutaneously, was begun at 14-26 weeks' gestation. Initially, the rise in hematocrit averaged 0.6-2% each week, with peak values of 26.7-32%. Iron supplementation was given simultaneously. Maternal and neonatal outcomes were favorable despite the development of preeclampsia or worsening renal function requiring early delivery. CONCLUSION: In this small series, erythropoietin begun during the second trimester in a dose of about 100 U/kg/week, in conjunction with orally administered iron, appeared to be effective in treating the anemia of renal failure during pregnancy. Additional experience is needed to evaluate the safety of this medication during pregnancy.

Adult↗
PubMed1992

Calcium mass transfer in peritoneal dialysis patients using 2.5 mEq/l calcium dialysate.

Standard peritoneal dialysate has a relatively high calcium concentration of 3.5 mEq/l. Peritoneal dialysis patients thus gain calcium from the dialysate which contributes to the risk of hypercalcemia. Dialysate with 2.5 mEq/l calcium is now available. Theoretically, using dialysate with this calcium content, calcium transfer should be negative (from the patient into the dialysate) when the patient is hypercalcemic, and positive when the patient is normocalcemic or hypercalcemic. Thus, 2.5 mEq/l calcium dialysate may allow larger doses of calcium carbonate to be prescribed. We compared calcium mass transfer (CMT) in 17 stable peritoneal dialysis patients using 3.5 and 2.5 mEq/l calcium dialysate. A solution of 2.05 l, 1.5 g/dl dextrose was dwelled for 4 hours. Calcium was measured in the drained dialysate and serum (total and ionized). Mean CMT was 0.7 +/- 0.5 mEq/exchange using 3.5 mEq/l calcium dialysate and -0.9 +/- 0.9 mEq/exchange using 2.5 mEq/l calcium dialysate (p less than 0.0001). At the time of the CMT studies, the mean serum ionized calcium levels were identical for the two groups (2.6 mEq/l). CMT correlated inversely with serum total calcium, serum ionized calcium, and drained dialysate volume. During hypercalcemia calcium transfer was from the dialysate to the patient when 3.5 mEq/l calcium dialysate was used, but from the patient to the dialysate when 2.5 mEq/l calcium dialysate was used. We conclude that 2.5 mEq/l calcium dialysate is effective in removing calcium and will be helpful in preventing hypercalcemia when large doses of oral calcium compounds are prescribed as a phosphate binder.

Adult↗