Biomedical subjects
Publications and source records attributed to S I Vas.
Access to dialysis is the most infection prone part of any dialysis system. The prophylactic management of the exit site, the various access systems and their role in infections is discussed. Methods are suggested to avoid or control infections.
Renal cell carcinoma is a rare but serious complication in ESRD patients. In these patients the incidence of renal cell carcinoma (RCC) is 20-40 times higher than in the general population. We performed a retrospective study to measure the incidence rate, prevalence, characteristics and survival among our peritoneal dialysis (PD) patients diagnosed with renal cell carcinoma. The study was carried out among 607 patients who were on the PD program from January 1997 to June 2002. RCC was detected in eight patients (four males and four females) with mean age of 52.1 +/- 10.6 years. Among these eight patients four were new cases that were diagnosed before the patients were started on dialysis (three in native kidneys and one in a transplanted kidney). In the other four patients the RCC was diagnosed after they had been on dialysis for 33-204 months (mean 60.75 +/- 50.48). We found an incidence rate of 1.3 per 1000 patients per year and a prevalence of 1.3%. Six of the eight patients had renal cysts. Tumor size was less than 7 cm in seven patients and in the other patient it was 8.5 cm. Seven of eight patients were alive at the time of study with a survival time ranging from 3-138 months (mean 122.25 +/- 88.2) months. In one patient, the RCC metastasised to the scalp, and, in two other patients, the tumors subsequently involved the second kidney. A cardiovascular complication was the cause of one death. Two patients received a renal transplant 36 and 66 months after diagnosis. We conclude that despite the low rate of metastases and mortality in our study, regular ultrasonography should be added to the follow-up of PD patients. Renal transplantation can be considered in these ESRD patients with RCC; however, close follow-up for metastases is recommended.
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BACKGROUND: During the past few decades the pattern of end-stage renal failure disease has changed with increasing number of elderly patients admitted for dialysis. In spite of their increasing number, little is known about the optimal mode of therapy of the 'old old' (those >or=80 years) patients. METHODS: In this retrospective study, we analysed the results of treatment of 31 non-institutionalized 'old old' patients at Toronto Western Hospital (17) and Scarborough General Hospital (14) and seven institutionalized patients in chronic care, Riverdale Hospital. The patients were on CAPD with Twin-bag Baxter (28) or Home Choice, Baxter or Fresenius CCPD system (10). Patients were screened at the CAPD clinic when routine blood investigations were done. Patient and technique survival, initial and final laboratory data (last visit or before death) and complications related/unrelated to dialysis method are presented. RESULTS: Multiple comorbid conditions were present at the start of the treatment and new added during treatment; very few were dialysis-related. The majority of non-institutionalized patients required assistance of home-care nurse to perform dialysis. Peritonitis (1/28.6 patient months) and exit-site infection rate (1/75.1 patient months) were low and responded to treatment. Incidence of peritonitis was higher among institutionalized debilitated patients (1/5.3 patient months). Incidence of hospitalization was 1/14.7 patient months and patients spent in hospital 7.5 days/patient year. Forty-seven per cent of patients survived 24 months; 39% survived 30 months. Technique survival was 91.5% at 12 months and 81.4% at 30 months. Poor appetite and malnutrition were frequent among very old patients. Patients and their families were motivated for treatment and discontinuation of dialysis was not higher than described elsewhere in literature. CONCLUSIONS: This study has demonstrated that chronic peritoneal dialysis could be recommended as a safe and suitable modality of treatment of end-stage renal failure in old old patients.
BACKGROUND: Hypertension is the prime contributor for cardiovascular mortality in the dialysis population. Peritoneal dialysis (PD) has been thought to improve blood pressure (BP) control in the short term, but the long-term benefits are not conclusively proven. We aimed to evaluate the degree of BP control in PD patients in the long term and analyse the factors associated with poor control. METHODS: Data of all patients who were initiated on PD at one centre between July 1994 and July 1998 and completed at least 1 year of PD were analysed retrospectively at initiation of PD, at 6 months, and annually thereafter until 5 years or until discontinuation of therapy. Hypertension was defined as per WHO/ISH criteria. A 'Blood Pressure Control Index' was empirically defined to account for the effect of antihypertensives on measured BP. Factors associated with poor BP control were analysed. RESULTS: Out of 207 patients (age 57.0+/-16.0 years, 103 male, 104 female) 91.3% were hypertensive at the start of PD. About 33.8% had diabetic nephropathy. Systolic and mean arterial pressure index improved in early phase reaching a nadir between 6 months and 1 year followed by steady progressive worsening through out the rest of follow up. On multiple linear regression analysis age (P<0.001), duration of hypertension prior to dialysis (P<0.001), and declining residual renal function, expressed as both average of urea and creatinine clearance (P=0.002) and residual urine output (P<0.001) were independently associated with poor BP control. Diabetes (P=0.836), peritoneal transport (D/P 4 of creatinine at start) (P=0.218), peripheral oedema (P=0.479) and dose of erythropoetin (P=0.488) were not associated. CONCLUSIONS: Initiation of PD results in early improvement of hypertension in end-stage renal disease (ESRD). BP control thereafter deteriorates steadily with time and this is associated with age, duration of hypertension, and declining residual renal function. This suggests that hypertension in ESRD patients is a progressive disease primarily related to falling glomerular filtration rate, the preservation of which might improve BP control and possibly modify cardiovascular risk.
We reviewed the course and outcome of all Pseudomonas aeruginosa (PA) exit-site and tunnel infections (ESI/TI) that occurred at our home peritoneal dialysis (PD) unit over a 3-year period (July 1995 to June 1998). We documented PA ESI/TI in 19 out of a total of 467 patients. Of the 19 patients, 12 having local redness and tenderness but no discharge were treated conservatively with increased frequency of dressing with or without hydrogen peroxide locally. Of the 12 cases receiving local care, 7 resolved without recurrence over 14.4 months follow-up, while the remaining 5 developed persistent ESI/TI with discharge and required treatment with antibiotics. Seven more patients who initially presented with purulent discharge also received systemic antibiotics. Only 1 of the 12 patients with PA ESI/TI treated with antibiotics resolved; the remaining 11 patients developed PA peritonitis over a 1-month to 7-month period after the initial PA ESI/TI. In 2 of these 11 patients, simultaneous PD catheter removal and replacement was attempted for the treatment of PA ESI/TI, but these patients also developed PA peritonitis 1-3 weeks after the procedure. Of the 11 patients with PA peritonitis associated with PA ESI/TI, 1 died, 6 were transferred to permanent hemodialysis, and just 4 continued PD after PD catheter replacement. Though not frequent, PA ESI/TI is still a serious complication of home PD at our unit, resulting in ESI/TI-related PA peritonitis and catheter loss in 58% of cases. Local treatment of mild PA ESI/TI (redness and induration) seems to be effective. On the other hand, patients with purulent discharge are likely to develop peritonitis and technique failure despite antibiotic therapy. Early catheter replacement can be considered in these cases.
OBJECTIVE: To call attention to the worldwide increase in tuberculosis and to review the disease in peritoneal dialysis patients. DATA SOURCES: Recent epidemiological publications. DATA EXTRACTION: Epidemiological data summarized in tables and diagnostic and therapeutic recommendations reviewed. CONCLUSIONS: Tuberculosis is on the rise worldwide. Multiple drug-resistant strains are emerging, causing therapeutic problems. The role of atypical mycobacterial infections in continuous ambulatory peritoneal dialysis (CAPD) is reviewed. Early diagnosis of cases and thorough chemotherapy are advocated.
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Toxicity of aminoglycosides is a major concern in the treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. The relatively high blood levels and prolonged and repeated usage may all be contributory. The recognition of the so-called postantibiotic effect, together with the increased phagocytosis of antibiotic-treated cells, may introduce a new mode of therapy with once-daily dosage. Intermittent therapy with vancomycin is already generally accepted. The extension of this modality to antibiotic therapy is discussed.
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Viruses may be the cause of renal disease. This effect may be direct, affecting the renal parenchyma, or may be indirect, usually through immune complex damage. The classification and potential role of viruses involved in renal damage is discussed.
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A case of disseminated blastomycosis in a male renal transplant recipient is presented. Discontinuation of immunosuppressive therapy and treatment with high-dose ketoconazole was successful in treating the patient's cutaneous and pulmonary disease initially. Ketoconazole was discontinued after 12 months of chronic therapy, but 2 weeks after discontinuation, blastomycosis recurred. High-dose ketoconazole was again effective; the patient remains asymptomatic presently on chronic suppressive therapy with ketoconazole.
Hepatic steatosis and steatonecrosis occur in nonalcoholic individuals, usually in a setting of obesity, type II diabetes mellitus, and after jejunoileal bypass. We propose an hypothesis for the pathogenesis of these hepatic lesions based on an observation in peritoneal dialysis patients. Hepatic histology was examined at autopsy in 11 patients with type I diabetes mellitus and renal failure who had received i.p. insulin in conjunction with continuous ambulatory peritoneal dialysis (CAPD). Steatosis in a unique subcapsular distribution occurred in 10 of 11 patients treated with i.p. insulin and in 0 of 9 controls receiving CAPD without insulin. Three of the 11 had steatonecrosis, 2 of whom had Mallory bodies. We suggest that insulin has an important role in the pathogenesis of steatosis and steatonecrosis. In CAPD patients the lesions occurred only under the capsule where concentrations of insulin are high secondary to its i.p. administration. In obese patients the lesions occur throughout the liver where insulin concentrations are high because of elevated levels in the portal vein. Free fatty acids (FFA) are oxidized in the liver by a pathway that is blocked by insulin. In the presence of insulin, FFA are preferentially esterified into triglycerides which accumulate in large quantities leading to steatosis; small amounts of FFA escaping local control may lead to membrane injury and steatonecrosis. Steatosis and/or steatonecrosis will occur when there is insulin secretion sufficient to block FFA oxidation but not sufficient to block FFA mobilization from adipose tissue.(ABSTRACT TRUNCATED AT 250 WORDS)
In the last several years we have reached a certain plateau in the frequency of peritonitis seen in patients. Consequently, a peritonitis rate of one every two patient years may be acceptable. Further reduction of this peritonitis rate will require large efforts on all fronts. One will have to consider what the acceptable cost/risk of peritonitis is in peritoneal dialysis patients. New developments in catheter technology, improved connections, better understanding of patient selection and training programs, improved diagnostic and therapeutic methods in the management of peritonitis, and an understanding of the infectious and immune processes are eagerly awaited.
This paper describes a simple system for the performance of slow continuous hemodialysis (SCHD) as a means of treating difficult and complicated cases of oliguric acute renal failure. The method, which employs access to the circulation via a double-lumen central venous catheter and a BSM 22 blood systems module, can be performed safely in the intensive care unit of a general hospital if closely supervised by a trained nephrologist. The results of treating 16 consecutive cases of complicated acute renal failure in a large general hospital without a hemodialysis unit are described. The method, whose simplicity makes it suitable for intensive care unit nurses without previous hemodialysis training, was not associated with any serious accidents or complications, and was tolerated well by even the most critically ill and hemodynamically unstable patients. The advantages of this approach over more traditional continuous arteriovenous hemofiltration (CAVH) are discussed.