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Beth Piraino

Publications and source records attributed to Beth Piraino.

At least 19 recordsLinked to original sources
PubMed2006

The effect of coronary angiography on residual renal function in patients on peritoneal dialysis.

BACKGROUND: The risk of intravascular radiocontrast to residual renal function (RRF) in patients on peritoneal dialysis (PD) remains largely unknown. HYPOTHESIS: This study sought to estimate the effect of coronary angiography on RRF in patients on PD. METHODS: All patients at the VA Pittsburgh Healthcare System and University of Pittsburgh who underwent coronary angiography between 1993 and 2005 while on PD and who had RRF measured prior to angiography were identified retrospectively. For patients without a postprocedure RRF recorded, medical records were reviewed to determine whether anuria had developed. The longer-term rate of loss of RRF among cases was compared with a composite rate of decline in RRF among cases before angiography and matched controls. RESULTS: Twenty-nine patients with a mean preprocedure RRF of 4.4+/-3.2 ml/min/1.73m(2) were evaluated. Of these patients, 23 (79%) had postangiography RRF assessments (mean clearance 3.4+/-3.0 ml/min/1.73m(2)). One of the remaining six patients definitely became permanently anuric following angiography, one was lost to follow-up, and there was no postprocedure RRF assessment in four others. The rate of decline in RRF in the cases was similar to the composite rate (0.07 ml/min/1.73m(2)/month vs. 0.09 ml/min/1.73m(2)/month, p=0.53) CONCLUSION: The risk for permanent anuria in patients on PD undergoing coronary angiography appears to be quite small. Patients who do not develop anuria following coronary angiography have the same gradual rate of loss of RRF as other patients on PD. Providers should be vigilant in protecting RRF in patients on PD undergoing coronary angiography.

Anuria↗
PubMed2006

Peritoneal dialysis infections recommendations.

Peritonitis remains a serious problem in peritoneal dialysis patients accounting for technique failure and contributing to mortality. Many peritonitis episodes are due to contamination at the time of the exchange and exit site infections. Protocols can be implemented by programs to diminish the risk of infection. Careful training, especially in handwashing technique and in doing the connection, are critical for preventing contamination related peritonitis. Peritonitis due to exit site infections can be reduced by use of exit site antibiotic cream. Gentamicin as opposed to mupirocin exit site prophylaxis reduces not only S. aureus but also P. aeruginosa infections. Refractory exit site infections can be managed with simultaneous catheter replacement. Once peritonitis occurs, prompt institution of empiric antibiotics, dictated by the history of the program's infections, should be done. Initial therapy is then modified once the culture results are known. Catheters require removal if the peritonitis fails to resolve within 5 days of appropriate antibiotic therapy or if peritonitis is relapsing. Fungal peritonitis is best treated with prompt catheter removal. Implementation of protocols to prevent peritonitis and careful attention to both the organisms causing peritonitis and the rate of infection by a peritoneal dialysis center are essential for reducing infectious complications. Once infections occur, rapid steps to treat and manage are important to diminish the risk of mortality and subsequent peritoneal damage, areas requiring more research.

Bacterial Infections↗
PubMed2005

A preliminary study of PDA-based dietary self-monitoring in hemodialysis patients.

OBJECTIVE: The purpose of this study was to pilot test an intervention to enhance the adherence of study participants to the hemodialysis dietary regimen. DESIGN: A single case study design was used to examine the potential effectiveness of the intervention over a 4-month period of time. SETTING: A dialysis center in southwestern Pennsylvania. PATIENTS: Of the five individuals entered into the study, one was male and four were female, four were black, and one was white. Participants were 63 to 70 years of age, and had been receiving dialysis for a median of 36 months (range, 18 to 84 months). INTERVENTION: The intervention included counseling to enhance self-efficacy, by a renal dietitian, paired with personal digital assistant-based dietary self-monitoring. Participants met twice per week with interventionists during the first 6 weeks, weekly during the second 6-week period, and biweekly in the final 4-week period. MAIN OUTCOME MEASURES: Monthly laboratory data regarding serum albumin, potassium, and phosphorus levels; Kt/V; and data on average monthly interdialytic weight gain were abstracted from the participants' medical records. C-reactive protein level was determined at baseline and at 4 months. RESULTS: Four of five study participants had an increase in serum albumin level from baseline to their final measurement, and one participant maintained a stable albumin level. Four of five participants also experienced a small increase in serum phosphorus level. Mixed results were obtained with regard to serum potassium and average monthly interdialytic weight gain. CONCLUSIONS: Because of the small sample and single case study design, caution must be used in drawing firm conclusions from this study. Data suggest that the intervention may result in improved dietary intake and improved serum albumin levels. With increased dietary intake, serum phosphorus levels may increase. Additional research is needed to determine the potential efficacy and cost-effectiveness of this intervention for improving dietary adherence.

Aged↗
PubMed2004

Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients.

Infection is the Achilles heel of peritoneal dialysis. Exit site mupirocin prevents Staphylococcus aureus peritoneal dialysis (PD) infections but does not reduce Pseudomonas aeruginosa or other Gram-negative infections, which are associated with considerable morbidity and sometimes death. Patients from three centers (53% incident to PD and 47% prevalent) were randomized in a double-blinded manner to daily mupirocin or gentamicin cream to the catheter exit site. Infections were tracked prospectively by organism and expressed as episodes per dialysis-year at risk. A total of 133 patients were randomized, 67 to gentamicin and 66 to mupirocin cream. Catheter infection rates were 0.23/yr with gentamicin cream versus 0.54/yr with mupirocin (P = 0.005). Time to first catheter infection was longer using gentamicin (P = 0.03). There were no P. aeruginosa catheter infections using gentamicin compared with 0.11/yr using mupirocin (P < 0.003). S. aureus exit site infections were infrequent in both groups (0.06 and 0.08/yr; P = 0.44). Peritonitis rates were 0.34/yr versus 0.52/yr (P = 0.03), with a striking decrease in Gram-negative peritonitis (0.02/yr versus 0.15/yr; P = 0.003) using gentamicin compared with mupirocin cream, respectively. Gentamicin use was a significant predictor of lower peritonitis rates (relative risk, 0.52; 95% confidence interval, 0.29 to 0.93; P < 0.03), controlling for center and incident versus prevalent patients. Gentamicin cream applied daily to the peritoneal catheter exit site reduced P. aeruginosa and other Gram-negative catheter infections and reduced peritonitis by 35%, particularly Gram-negative organisms. Gentamicin cream was as effective as mupirocin in preventing S. aureus infections. Daily gentamicin cream at the exit site should be the prophylaxis of choice for PD patients.

Administration, Topical↗
PubMed2004

Inter-rater reliability and annual rescoring of the Charlson comorbidity index.

A measure of comorbidity in dialysis patients must not only predict outcomes but also be reproducible and easy to obtain. Our primary purpose in the present study was to determine the inter-rater reliability of the Charlson comorbidity index (CCI) in peritoneal dialysis (PD) patients. Our secondary purpose was to evaluate the usefulness of annual rescoring of the CCI as a predictor of patient survival. We included in the study 100 consecutive patients (mean age: 52 +/- 16 years; 85% white; 39% with diabetes) who started PD between 1995 and 2000 at a single center: Two nurses independently scored the CCI at the start of PD. One nurse rescored each patient on the yearly anniversary of the start of PD. Patient survival was recorded for each year Kappa score and time-dependent analysis were applied. The kappa score between the two CCI scores at the start of dialysis was 0.93. (The average scores by the two nurses were 5.2 and 5.3.) Annual rescoring of the CCI demonstrated no increase in its predictive value regarding patient survival. However, given the minimal change in the CCI for the patient population in the present study, that question needs further study. Over time, the average CCI fell--an unsurprising result, because patients with higher CCI scores at the start of dialysis are the most likely to die. We conclude that the CCI is a reliable and easily applied tool for assessing comorbidity. Dialysis units should consider obtaining this measure at the start of dialysis in all patients. Repetitive annual scoring was not helpful in improving prediction of survival.

Comorbidity↗
PubMed2003

New insights on preventing and managing peritonitis.

Methods to prevent peritonitis are an essential component of any successful peritoneal dialysis (PD) program. Careful attention to training of the parents and child on the proper technique of PD and avoidance of manual spiking by using an assist device for the cycler, or use of the double-bag system for continuous ambulatory PD, should decrease risk of peritonitis from touch contamination. Secondly, reduction of peritonitis can be achieved through reduction of exit site infections by use of mupirocin antibiotic cream at the exit site of the PD catheter as part of routine care. If an exit site infection develops and is refractory to therapy, then the PD catheter can be successfully replaced as a single procedure, to reduce the risk of peritonitis. The third step in reducing the risk of peritonitis is to avoid repetitive episodes with the same organism. This may again involve replacing the catheter; as long as the effluent can be cleared, this again can be performed as a single procedure, thus allowing the child to avoid the trauma of hemodialysis. The focus in pediatric PD programs must always be on preserving the peritoneal membrane, and not on preservation of the catheter. With careful attention, peritonitis can become an uncommon event.

Humans↗
PubMed2003

Albumin at the start of peritoneal dialysis predicts the development of peritonitis.

BACKGROUND: Both peritonitis and serum albumin level are associated with morbidity and mortality in peritoneal dialysis (PD) patients. Severe cases of peritonitis result in hypoalbuminemia. However, it is not clear whether hypoalbuminemia predicts the development of peritonitis. METHODS: We performed a retrospective analysis of a prospectively collected database from six centers in western Pennsylvania and West Virginia. Incident PD patients with a Charlson Comorbidity Index (CCI) score at the start of PD therapy and serum albumin level measured within 30 days of initiation were selected. Poisson regression was used to analyze predictors of peritonitis. RESULTS: Three hundred ninety-three patients had a CCI score and serum albumin level measured at the start of PD therapy. Overall peritonitis rate was 0.65 episodes/dialysis-year. Significant univariate predictors were albumin level (rate ratio [RR], 0.79 per 1-g/dL [10-g/L] increase; 95% confidence interval [CI], 0.65 to 0.95; P = 0.015), male sex (P = 0.003), and being dialyzed in the Veterans Administration (RR, 1.97; 95% CI, 1.48 to 2.62; P < 0.001) or other center (RR, 1.68; 95% CI, 1.92 to 5.62; P < 0.001). Although CCI score correlated inversely with albumin level (r = -0.305; P < 0.001), CCI score was only marginally predictive of peritonitis (P = 0.068). In multivariate analysis, predictors were albumin level (RR, 0.74; 95% CI, 0.31 to 1.75; P = 0.002) and race (RR, 1.36; P = 0.024). Patients with an initial serum albumin level less than 2.9 g/dL (29 g/L) had a peritonitis rate of 1.5 episodes/dialysis-year compared with 0.6 episodes/dialysis-year for patients with an initial serum albumin level of 2.9 g/dL or greater (P < 0.001). CONCLUSION: Hypoalbuminemia at the start of PD therapy is an independent predictor of subsequent peritonitis. Intervention studies to decrease peritonitis risk in this high-risk subset of patients are needed.

Adult↗
PubMed2003

Nightly intermittent peritoneal dialysis to initiate peritoneal dialysis.

Nightly intermittent peritoneal dialysis (NIPD) with no day dwell has the potential to enhance peritoneal host defenses. We evaluated outcomes in 24 patients who had been placed on NIPD at the start of peritoneal dialysis as compared with outcomes of 24 control patients on standard continuous cycling peritoneal dialysis (CCPD). As compared with patients on CCPD, patients on NIPD had a lower peritonitis rate (0.34 episodes/year vs. 0.59 episodes/year, p < 0.03) and fewer hospital admissions (1.0 admission/year vs. 1.6 admissions/year, p = 0.003). The weekly initial KtV was similar in NIPD and CCPD, but NIPD had significantly higher creatinine clearances owing to higher glomerular filtration rates (GFRs) among the patients (7.8 mL/min vs. 4.8 mL/min, p < 0.02). Technique and patient survival were similar in both groups after controlling for the difference in initial GFR. We conclude that NIPD is a good modality choice for patients starting PD with residual renal function and that it present a low peritonitis risk. As GFR declines, a last fill can be added to maintain adequate clearances.

Creatinine↗
PubMed2002

A randomized controlled trial to evaluate the efficacy and safety of icodextrin in peritoneal dialysis.

BACKGROUND: This article presents the results of two randomized, double-blind, controlled studies conducted to compare the efficacy and long-term safety of icodextrin and 2.5% dextrose for the once-daily long dwell in continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). METHODS: Both studies were active-control comparisons of 7.5% icodextrin and 2.5% dextrose for the once-daily long dwell. The efficacy study was a 4-week evaluation of net ultrafiltration and peritoneal clearances of creatinine and urea nitrogen in 175 CAPD patients. The 52-week study in CAPD and APD patients examined the long-term safety of icodextrin and longer term effects, such as body weight and quality of life. RESULTS: Mean net ultrafiltration (587.2 versus 346.2 mL, P < 0.001) and clearances of urea nitrogen (4.5 versus 4.1 mL/min, P < 0.001) and creatinine (4.0 versus 3.5 mL/min, P < 0.001) were increased significantly with icodextrin. Patients receiving icodextrin had no increase in weight after 52 weeks, in contrast to a weight gain of almost 2 kg in the dextrose group (P < 0.05). There were significantly fewer patients reporting edema in the icodextrin group compared with the dextrose group (6.3% versus 17.9%, P < 0.01). There were no statistically significant differences between groups for the incidence and severity of adverse events. There were small decreases in sodium and chloride and increases in alkaline phosphatase with icodextrin. CONCLUSION: Icodextrin provides patients with greater fluid removal and small solute clearance, no weight gain over 52 weeks, and a decreased risk of edema.

Adult↗
PubMedDate not supplied

Characteristics of depression in hemodialysis patients: symptoms, quality of life and mortality risk.

BACKGROUND: Depression is often underrecognized in patients with end-stage renal disease. We interviewed outpatients at an urban dialysis facility using a criterion-based case-finding instrument to assess the rates, clinical correlates and outcomes of depression. METHODS: The Primary Care Evaluation of Mental Disorders Mood Module and the nine-item Patient Health Questionnaire were used to assess depression. We measured health-related quality of life using the Kidney Disease and Quality of Life Short Form, and medical comorbidities were measured using the Charlson Comorbidity Index. We compared the sociodemographic and clinical characteristics and health-related quality of life of depressed and nondepressed patients using t tests and the chi-square test, and we used a Cox regression model to test the relationship between depression and mortality. RESULTS: We interviewed 62 patients and followed them for a mean of 29 months (range, 0.1-36). Seventeen (28%) had major or minor depression. Depressed patients were younger and had lower health-related quality of life than did nondepressed patients. Depression predicted mortality (HR=4.1, 95% CI=1.5-32.2, P<.05) after adjusting for age, gender, race, medical comorbidities, albumin, kt/V and/or the presence of diabetes. CONCLUSIONS: Depression is common and associated with decreased health-related quality of life and increased mortality in hemodialysis patients. Clinical trials are necessary to examine whether treatment of depression can improve these outcomes.

Adolescent↗
PubMedDate not supplied

Intra-abdominal pressure, peritoneal dialysis exchange volume, and tolerance in APD.

Automated peritoneal dialysis (APD) is increasingly popular compared to continuous ambulatory peritoneal dialysis (CAPD). It not only can provide more solute clearance and ultrafiltration than its CAPD counterpart, but it is conducive to a more convenient lifestyle as well. Using relatively smaller-volume daytime dwells, with the use of larger-volume exchanges while the patient is recumbent during the night, is an attractive approach. Advantages of supine exchanges include greater small molecule clearances for equivalent flow rates and decreased intra-abdominal pressure per volume of dialysate (as intraperitoneal pressure parallels intraperitoneal volume). Urea nitrogen clearance can be optimally increased on APD by increasing both the exchange volume and the frequency of exchanges at night. This is even true for anuric low transporters. This approach allows daytime exchanges and volumes to be minimized. Historic studies in peritoneal dialysis including flow rate analysis, clearance and adequacy studies, as well as tolerance have primarily involved CAPD. As a result, there is a paucity of investigations involving APD. More research is required in APD related to these subjects.

Abdomen↗
PubMedDate not supplied

Peritoneal dialysis catheter replacement: "save the patient and not the catheter".

A 63-year-old man on ambulatory peritoneal dialysis (APD) developed peritonitis with Enterococcus faecalis, treated with 2 g intraperitoneal (IP) vancomycin, with rapid clearing of the effluent white blood cells, but persistence of positive cultures. Vancomycin was redosed on day 8 (2 g IP), and then weekly. Gentamicin 140 mg IP loading dose, followed by 40 mg IP once a day was added after cultures were still positive at 2 weeks. The two drugs were continued for six additional weeks. Although the patient was asymptomatic, the effluent cultures continued to grow E. faecalis and the catheter was replaced 2 months after the onset of peritonitis. There was no evidence of either tunnel infection or intra-abdominal abscess. Refractory peritonitis is defined as continuation of peritonitis after 5 days of appropriate therapy. This patient had persistently positive cultures but quickly became asymptomatic and signs of inflammation resolved readily. The most likely etiology appears to have been colonization of the slime layer of the intra-abdominal portion of the catheter with the organism. The vancomycin dosing schedule may have played a role in the persistently positive cultures. A recent pharmacokinetic study suggested that patients on APD require 35 mg/kg IP of vancomycin as a loading dose, followed by 15 mg/kg IP once a day, given in a long day exchange. Simultaneous placement and removal as a single procedure was successful in this patient and can be done safely in patients whose effluent white blood cell count (WBC) is less than 100/mm3. Most patients can then be subsequently managed by doing supine dialysis (using a cycler) with decreased exchange volumes and a dry abdomen until healing occurs (usually 1-2 weeks). In this way hemodialysis can be avoided. By minimizing the effect on the patient's lifestyle, the patient is more likely to agree to a catheter exchange.

Anti-Bacterial Agents↗
PubMedDate not supplied

Quality of life and psychological issues in peritoneal dialysis patients.

Both peritoneal dialysis (PD) and hemodialysis (HD) patients have diminished quality of life (QOL) scores compared to healthy patients. QOL tends to decline over time, with the perception of the quality of physical health deteriorating more than mental health. However, many patients continue to feel hopeless, anxious, and worry about finances, loss of sexual function, family burden, and loss of independence. Depression is the most widely acknowledged psychosocial factor seen in patients with chronic kidney disease. Major depression occurs in 25% of patients facing impending dialysis. Once on PD, the proportion with major depression sharply declines to approximately 6%. This may be due to adjustment to dialysis, but may also be because depressive symptoms are associated with an increased risk of death. A low QOL score and depression are associated with higher comorbidity, poorer nutritional status, anemia, lower residual renal function, and increased hospitalization rates. Increased depressive scores are independently predictive of an elevated peritonitis risk, perhaps due to inattentiveness, or alternatively from a decrease in immune defenses. Small molecule clearances appear to have little to do with depressive symptoms. Depression is a significant problem in PD and other dialysis patients. There is an interrelationship between psychosocial factors, perception of illness, and clinical outcome that requires further study. Serial and simple measures of both depression and QOL should be obtained routinely in all PD patients. This permits rapid recognition of problems and may enhance patients' education on the importance of depression. Further research on interventions is urgently needed.

Depression↗
PubMedDate not supplied

Large body mass index does not predict short-term survival in peritoneal dialysis patients.

OBJECTIVE: Higher than normal body mass index (BMI) is associated with an increased risk of death in the general population. We examined the effect of higher than normal BMI on patient and technique survival in peritoneal dialysis patients (PD), controlling for comorbidity, initial albumin, dialysate-to-plasma ratio of creatinine (D/P(Cr)), and initial urea clearance (Kt/V). DESIGN: Registry database. SETTINGS: Four dialysis centers. PATIENTS: Incident PD patients. METHODS: All data were collected prospectively. Demographics, BMI, serum albumin, D/P(Cr), and comorbidity using the Charlson Comorbidity Index (CCI) were determined at the start of PD. 104 patients with a high BMI (> 27) were matched to a control group of 104 patients with normal BMI (20-27) for age, gender, presence of diabetes, and CCI. Patient and technique survival were compared using Cox proportional hazards model. MAIN OUTCOME MEASURES: Patient and technique survival. RESULTS: The groups were of similar age (56.1 vs 56.7 years), sex (60% males in both groups), race (Caucasian 80% vs 86%), presence of diabetes (40% vs 37%), CCI score (5.4 in both groups), initial albumin (3.6 vs 3.5 g/dL), and D/P(Cr) (0.65 in both groups). Kaplan-Meier survival analysis showed similar 2-year patient survival between large BMI (> 27) and control (20-27) groups (76.6% vs 76.1%). Two-year technique survival was also similar between the two groups (59.7% vs 66.8%). With Cox proportional hazards analysis, BMI was not a predictor of patient mortality or technique survival when controlling for initial albumin, D/P(Cr), and initial Kt/V. CONCLUSIONS: We conclude that a BMI above normal is not associated with any increased or decreased risk of death in patients on PD for 2 years.

Body Mass Index↗