Charge selectivity of peritoneal transport in CAPD patients under stable states and during peritonitis

To investigate charge selectivity of peritoneal transport in CAPD, dialysate/plasma concentration ratios (D/P) were calculated for creatinine (Cr) and 3 amino acids with almost the same molecular weight but quite different charges: glutamic acid (Glu: negatively charged), glutamine (Gln: near neutrally charged) and lysine (Lys: positively charged). The study population consisted of 23 stable patients and 11 patients with peritonitis on CAPD. In the stable patients, the samples of dialysate were taken at 2 and 4 hours and blood samples were obtained at 4 hours after the infusion of 2 liters of 2.27 or 2.5% glucose CAPD dialysate; the samples of patients with peritonitis were obtained at 4.1 +/- 1.1 hours of dwell time. In stable patients, D/P of Glu was much lower than the values for Gln, Lys and Cr at both 2 and 4 hours (p < 0.01), and D/P of Lys was significantly lower than that of Gln (p < 0.01). There was no significant difference in D/P between Gln and Cr. In patients with peritonitis, D/P of Glu was also significantly lower than the values for Gln and Cr (p < 0.05 and p < 0.01), however, no significant differences were found between D/P of Lys and the values of Glu and Gln. Ratios of both [D/P Glu]/[D/P Lys] and [D/P Glu]/[D/P Gln] were much higher in peritonitis patients than in stable patients. In conclusion, peritoneal transport in stable CAPD patients shows charge selectivity, and the order of molecular charge for transperitoneal mobility among small solutes is neutral > positive > negative. The selectivity, however, is decreased or lost during peritonitis.     

Continuous ambulatory peritoneal dialysis--an effective method of treatment in chronic renal failure

The authors evaluate the results of treatment of continuous ambulatory peritoneal dialysis (CAPD) in seven patient with chronic renal failure during a 12-month period. The baseline examination was made one month before CAPD was started, one day before insertion of a Tenckhoff catheter and then after 1, 3, 6 and 12 months of treatment. The highest assessed mean serum urea concentrations during treatment were 19.8 +/- 2.3 mmol/l (arithmetic mean +/- SE of the mean), creatinine 815.1 +/- 43.1 mmol/l. The haematocrit improved significantly due to CAPD. From the mean value of 22.5 +/- 1.7% recorded one month before treatment it increased to 32.8 +/- 2.5% after 12 months of therapy. In five patients CAPD made it possible to discontinue and in two to reduce antihypertensive medication. During the investigation period the authors did not detect a drop of total protein and albumin in serum. Serum cholesterol increased significantly during treatment. Peritonitis was recorded four times during the total period of 70 months of treatment, i.e. on average one episode during 17.5 months of treatment. Based on their results the authors conclude that CAPD is at present one of the very effective methods of treatment of chronic renal failure. The incidence of peritonitis was already during the first year when treatment was initiated comparable with the results in departments where it is commonly used and after further experience it declined to one episode per 38.8 months of treatment. The method deserves wider application than hitherto.     

Nystatin prophylaxis: its inability to prevent fungal peritonitis in patients on continuous ambulatory peritoneal dialysis

OBJECTIVE: To evaluate the potential effectiveness of nystatin as prophylaxis for fungal peritonitis (FP) in patients on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: This historically controlled study was designed to investigate the effectiveness of nystatin in the prevention of FP. For this purpose we compared the incidence of FP among 240 (new and prevalent) CAPD patients between January 1996 and November 1996 (period A) with its incidence in 240 new and prevalent CAPD patients in our program between January 1997 and November 1997 (period B) when nystatin prophylaxis was used. There were 2400 patient-months in each period. Nystatin (500,000 IU four times per day), was given orally at the beginning of other antibiotic therapy (usually for peritonitis) and continued for 5 days after the end of the antibiotic therapy. RESULTS: During period A, 133 peritonitis episodes were recorded, and during period B, 99 episodes were recorded. Six episodes of FP were identified in over 2400 patient-months of period A, and 12 in over 2400 patient-months of period B. This difference was not statistically significant. Three episodes of antibiotic-related FP were seen in period A, and four in period B. The remaining episodes arose de novo, that is, unrelated to the use of antibiotics. We observed no side effects for nystatin. CONCLUSION: In CAPD patients the use of nystatin, a nonabsorbable antifungal agent, as prophylaxis in every instance of peritonitis or other indications for antibiotics, did not lower the incidence of fungal peritonitis.     

Regulation of early cholesterol biosynthesis in rat liver: effects of sterols, bile acids, lovastatin, and BM 15.766 on 3-hydroxy-3-methylglutaryl coenzyme A synthase and acetoacetyl coenzyme A thiolase activities

BACKGROUND: Sclerosing peritonitis (SP) is a rare but serious complication of peritoneal dialysis (PD). Small-bowel obstruction (SBO) due to encapsulation, dense adhesions, or mural fibrous is characteristic, often associated with peritonitis. The aim of the study was to determine the incidence, clinical features, effect of duration of dialysis, and other possible aetiological factors in severe SP. METHODS: All dialysis units in Australia were surveyed for possible cases up to 1994. Patients were included if there was either surgical or radiological evidence of sclerosing encapsulating peritonitis or SBO with tanned or thickened peritoneum in the absence of other causes of SBO. RESULTS: Fifty-four patients were analysed. The duration of continuous PD was mean 52 +/- 30 months, median 48 months and range 8-127 months. Nineteen cases were diagnosed between 1980 and 1989 and 35 between 1990 and 1994, giving mean annual incidences 1.9 and 4.2 per 1000 PD periods respectively. The overall prevalence was 0.7%, which increased progressively with the duration of PD being 1.9, 6.4, 10.8, and 19.4% for patients on dialysis for > 2, 5, 6 and 8 years respectively. Sclerosing encapsulating peritonitis was diagnosed in 87% of cases, SBO in 92%, and haemoperitoneum in 8%. Peritoneal calcification was present in seven cases, all of which had been on PD > 7 years. Peritonitis was associated with 38% of cases with fungal infection in 7%. Treatment with immunosuppression in five patients appeared to result in a favourable outcome in three. The mortality rate was 56%. CONCLUSION: Severe sclerosing peritonitis is a serious complication of peritoneal dialysis and there is a time dependent increase on CAPD.     

Failure to cure Mycobacterium gordonae peritonitis associated with continuous ambulatory peritoneal dialysis

Nontuberculous mycobacteria are increasingly recognized as important pathogens in peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD). Mycobacterium gordonae rarely causes human infection and is the least likely mycobacterium to produce clinical infection in CAPD patients. We describe a patient with persistent M. gordonae peritonitis acquired while undergoing CAPD. During 18 months of treatment, clinical improvement occurred but a microbiological cure could not be achieved. Principles of therapy for mycobacterial peritonitis developing during CAPD are reviewed, and potential explanations for our patient's failure to respond to therapy are discussed.     

Icodextrin use in CCPD patients during peritonitis: ultrafiltration and serum disaccharide concentrations

BACKGROUND AND METHODS: In a randomized study on the biocompatibility of icodextrin (I) versus glucose (G) in CCPD we used icodextrin or glucose for the long daytime dwell. During the night-time dwells glucose was used in all patients. In case of peritonitis icodextrin was continued. In all patients ultrafiltration (UF) was recorded and serum icodextrin metabolites were determined every 3 months and during peritonitis in I-users when available. RESULTS: Thirty-eight patients ( 19 G, 19 I) entered the study and suffered 30 peritonitis episodes (16 G, 14 I). During peritonitis (P), daytime dwell UF decreased significantly in G (P=0.001), but remained stable in I patients compared to non-peritonitis (NP) episodes. Total 24-h UF decreased in G (P=0.001) and in I patients (P=0.04), as the result of a decreased daytime UF and night-time UF, respectively. There was no difference in the used glucose concentrations during the P versus NP episodes. In five I-patients serum disaccharides increased from 0.05+/-0.01 to 1.26+/-0.23mg/ml during follow up. During peritonitis serum disaccharide concentrations did not increase further (1.47+/-0.24 mg/ml, P= 0.56). In I patients total carbohydrate minus glucose rose to 5.72 +/- 1.2 mg/ml during follow up, and to 6.63 +/- 1.04 mg/ml during peritonitis (P=0.7). These concentrations are comparable to CAPD patients despite the longer dwelltime in CCPD (8-10 versus 14-16 h, respectively). Adverse reactions attributable to icodextrin were not encountered. CONCLUSIONS: In contrast to glucose, icodextrin preserved the daytime dwell ultrafiltration during peritonitis. Serum icodextrin metabolites increased during icodextrin use, but remained stable during peritonitis. Adverse effects were not observed.     

Prevalence of histological beta2-microglobulin amyloidosis in CAPD patients compared with hemodialysis patients

BACKGROUND: The prevalence of beta2-microglobulin amyloidosis (Abeta2m) in patients on continuous ambulatory peritoneal dialysis (CAPD) is unknown. METHODS: We prospectively obtained a median of 2 (range 1 to 4) joint samples from 26 CAPD patients aged 44 to 93 (median 73) years at post-mortem evaluation after 4.5 to 126 (median 27) months solely on CAPD (N = 19) or primarily on CAPD (that is, < or = 10% and < or = 1 year of renal replacement therapy time on other modalities; N = 7). The diagnosis of Abeta2m rested on Congo red staining (typical birefringence) and positive immunostaining of amyloid deposits by a monoclonal anti-beta2m antibody. RESULTS: Abeta2m was diagnosed in 8 of 26 patients (31%). Prevalence ranged from 20% (2 of 10 patients) within < or = 24 months CAPD to 30% (3 of 10 patients) after 24 to 48 months and 50% (3 of 6 patients) after 49 to 126 months (P = 0.11). The prevalence of Abeta2m was similar in patients without or with one or more peritonitis episodes. No significant difference in prevalence (P = 0.118) was found between CAPD patients (8+/26; 31%) and hemodialysis patients (13+/26; 50%) carefully matched for time on dialysis and age at the onset of dialysis. CONCLUSIONS: The prevalence of histological Abeta2m reaches 31% after a median duration of 27 months of CAPD. This prevalence is not significantly different from that observed in a group of HD patients matched for age and dialysis duration.     

Outcome of HIV infected patients on continuous ambulatory peritoneal dialysis

A retrospective analysis of 39 HIV infected patients with ESRD cared for in New Haven from 1987 to June 1992 was performed. All patients had evidence for HIV infection at the start of CAPD therapy. Cumulative technique survival at one and two years was 43% and 27%, respectively. Only eight patients transferred to center dialysis. One and two year patient survival on CAPD was 58% and 54%, respectively. Mortality was higher in patients with advanced infection than in those with asymptomatic HIV infection. Hospitalization rates were also higher in patients with advanced infection. HIV infected patients had higher rates of peritonitis (3.9 episodes/outpatient CAPD year) compared to non-HIV infected patients (1.5 episodes/CAPD year), especially for pseudomonal and fungal infections. Active injection drug use and use of the "straight set" system were associated with increased rates of peritonitis. CAPD deserves consideration as a therapy for HIV infected patients with ESRD.     

Randomized long-term evaluation of bicarbonate-buffered CAPD solution

BACKGROUND: Over the past 15 years, lactate has been used successfully as a buffer in peritoneal dialysis solutions, although its effectiveness in the correction of uremic acidosis and its biocompatibility on peritoneal resident cells have been questioned. In addition, some investigators have suggested other potential adverse metabolic effects resulting from the unphysiologically high lactate flux into the body during CAPD. These potential problems associated with lactate-containing CAPD solution prompted the search for alternative buffer-containing solutions. Bicarbonate, the physiological buffer, was considered when the problem of calcium and magnesium carbonate solubility was solved by the use of a two-compartment bag system, allowing the mixing of bicarbonate and divalent cations immediately before infusion. The long-term tolerance, safety, efficacy and therapeutic value of a bicarbonate-buffered peritoneal dialysis solution were evaluated in this study. METHODS: This open, randomized, controlled, multicenter study comparing a 34 mmol/liter bicarbonate- with a 35 mmol/liter lactate-buffered peritoneal dialysis solution was performed in two consecutive 12-week-treatment phases. Fourteen Centers participated in this trial. RESULTS: A total of 69 out of initially 123 randomized patients completed the six-month study period (36 patients in the bicarbonate group and 33 in the lactate group). While the arterial acid base status of the total study population did not change during the study period and no significant difference was observed between the two treatment groups, the acid-base status of patients in the bicarbonate group entering the study with a metabolic acidosis significantly improved (mean +/- SD; blood pH: baseline = 7.361 +/- 0.05, week 12 = 7.380 +/- 0.04, P < 0.05; week 24 = 7.388 +/- 0.03 P < 0.05; plasma bicarbonate: baseline = 19.49 +/- 3.01 mmol/liter, week 12 = 21.16 +/- 2.63 mmol/liter, P < 0.01; week 24 = 21.51 +/- 2.42 mmol/liter, P < 0.01). No significant changes were recorded in acidotic patients treated with the conventional lactate-buffered solution. The changes in plasma bicarbonate from baseline during the study was significantly different between the groups (week 12: lactate = +0.11 +/- 2.21 mmol/liter, bicarbonate = +1.69 +/- 2.55 mmol/liter, P < 0.05, 95% confidence interval for the difference 0.21 to 2.94 mmol/liter; week 24: lactate = +0.03 +/- 2.48 mmol/liter, bicarbonate = +1.82 +/- 2. 96 mmol/liter, P < 0.05, 95% confidence interval for the difference 0.16 to 3.42 mmol/liter). The normalized protein catabolic rate (nPCR) slightly but significantly decreased in the lactate group (baseline -0.90 +/- 0.23 g/kg/day, week 24 -0.83 +/- 0.21 g/kg/day, P < 0.01) and increased in the bicarbonate group (baseline +0.89 +/- 0.28 g/kg/day, week 24 +0.92 +/- 0.26 g/kg/day, P < 0.05). Changes from baseline between groups were significant (week 24, lactate = -0. 099 +/- 0.15 g/kg/day, bicarbonate = 0.049 +/- 0.12 g/kg/day, P < 0. 01, 95% confidence interval for the difference 0.068 to 0.229 g/kg/day). Other evaluated parameters (biochemical profile, peritoneal function parameters, dialysate protein loss) did not differ significantly between the two groups. No adverse effects related to the study solution were recorded. CONCLUSIONS: These results support the efficacy and safety of bicarbonate-buffered peritoneal solutions in a controlled randomized comparison for up to six months. Peritoneal dialysis solutions containing the physiological buffer bicarbonate might effectively replace conventional lactate-buffered CAPD solutions.     

Chronic renal replacement therapy in children: which index is best for adequacy?

BACKGROUND: The dialysis dose, Kt/V, and Solute Removal Index (SRI) have been proposed as tools to measure and compare adequacy of different renal replacement therapies in adults. The aim of our study was to elucidate whether the Kt/V and SRI could be appropriate parameters to compare different treatments and define adequacy targets in children. METHODS: Twenty-two pediatric chronic dialysis patients (2 to 17 years) were prospectively studied. Six patients were on continuous ambulatory peritoneal dialysis (CAPD), 7 patients were on automatic nightly peritoneal dialysis (ANPD), and 9 were on hemodialysis (HD). Patients had no peritonitis and were not hospitalized during the previous two months and, as proved by growth and subjective well being, were in steady state condition at the initiation of the protocol. As a consequence, the treatment delivered was assumed to be adequate and the prospective analysis was carried out within one month. Urea levels in dialysate, plasma and urine were measured to determine urea kinetics and measure adequacy parameters. RESULTS: Instantaneous urea clearance was much higher when hemodialysis was used (124.67 +/- 32.04 ml/min) compared to CAPD (2.79 +/- 0.29 ml/min) and ANPD (6.60 +/- 1.42 ml/min), as expected. The Urea dialytic clearance per week was greater in HD (67320 +/- 17299 ml) than in CAPD(28144 +/- 2895 ml) and ANPD (29910 +/- 4234 ml). Residual renal function contributed to the overall weekly clearance by 47% in CAPD, while it was only by 19% in HD and 26% in ANPD. The overall weekly clearance was therefore 79,842 ml/week in HD, 53,340 ml/week in CAPD and 41,012 ml/week in ANPD. Weekly dialytic Kt/V results were much higher in HD (3.75) than in CAPD (1.78) and ANPD (2.37). To these values, the renal Kt/V was added, reaching the values of overall (dialytic + renal) weekly Kt/V of 4.53 in HD, 3.41 in CAPD and 3.41 in ANPD. Although higher Kt/V values were observed in HD, when the SRI % was considered, HD appeared to be less efficient compared with the other two techniques. Since postdialytic rebound in HD patients averaged 22.5%, we may speculate that hemodialysis in children is less efficient than continuous or daily peritoneal dialysis because of a remarkable cardipulmonary recirculation and solute sequestration. CONCLUSION: In the global evaluation, dialysis SRI% appears to be more reliable as an index of adequacy compared to Kt/V in children. At least an integration between the two indices is strongly recommended.     

Peritonitis in continuous ambulatory peritoneal dialysis. Culture of peritoneal dialysate fluid

Conventional aerobic and anaerobic culture of peritoneal dialysate effluent from patients in continuous peritoneal dialysis (CAPD) was compared to culture in a semiautomated blood culture system. During a two-year period 78 of 79 consecutive episodes of peritonitis among 45 Danish CAPD patients were cultured and the etiology of the infection found in 73 (94%). The sensitivity of the blood culture system was 88%, whereas the sensitivity of the conventional culture of the dialysate effluent was 81%. This difference is not significant (McNemar test; 0.5 > p > 0.3). The majority of isolates were Gram-positive bacteria dominated by coagulase-negative staphylococci (38%). In comparison, only 2% of the cultures of peritoneal dialysate effluent taken within the same period from patients without clinical signs of peritonitis were positive. All the Gram-positive aerobic bacteria were sensitive to vancomycin whereas 97% of the Gram-negative aerobic bacteria were sensitive to gentamicin. An initial empiric treatment of peritonitis with a combination of vancomycin and gentamicin is recommended.     

Comparative experience of a simple technique for laparoscopic chronic ambulatory peritoneal dialysis catheter placement

BACKGROUND: Chronic ambulatory peritoneal dialysis (CAPD) is now an established technique for renal dialysis. Patients with renal failure cope poorly with major surgery and it is vital that the dialysis catheter tip is sited accurately in the pelvis if long-term catheter function is to be achieved. Laparoscopic placement of CAPD catheters may have potential advantages for renal patients by avoiding the morbidity of a laparotomy. METHODS: A retrospective audit was performed of all CAPD catheters inserted at the John Hunter Hospital over a 2-year period. Results of laparoscopically inserted catheters and those placed at laparotomy were compared. RESULTS: Sixty catheters were inserted, 30 laparoscopically and 30 at laparotomy. The mean operative time was 41 min in the laparoscopic patients and 57 min in the laparotomy patients (P = 0.0001). The mean total dose of narcotic administered postoperatively was significantly less in the laparoscopic group (5 mg vs 65 mg, P = 0.00002). There were three minor peri-operative complications in the laparoscopic group and seven peri-operative complications in the laparotomy group, three required reoperation and one resulted in the patient's death. There were no significant differences in the incidence of exit-site infection, catheter blockage, peritonitis, and overall catheter survival, although the laparoscopically placed catheters had been followed up for a shorter period (10 vs 16 months). CONCLUSIONS: This laparoscopic technique is safe and effective. Postoperative pain was less than for open placement. Laparoscopically placed catheters had a low incidence of peri-operative complications. Medium-term patency is similar to conventionally placed catheters. This procedure requires no additional equipment to that available for laparoscopic cholecystectomy and takes less time than the open operation.     

Schizophrenia, schizophrenia-like disorders and delusional disorders in patients with anorexia nervosa: literature review and report of 3 cases

This study compared specific phenotypic and potential virulence characteristics of Staphylococcus aureus isolates from invasive infections and nasal carriers. Three hundred and sixty isolates were studied; 154 from septicaemia (69 line associated, 85 non-line), 79 from continuous ambulatory peritoneal dialysis (CAPD) peritonitis, 64 from bone/joint infections and 64 from healthy nasal carriers. The isolates were tested for production of enterotoxins (SE) A, B, C or E, toxic shock syndrome toxin-1 (TSST-1) protein A, and also for lipolytic, proteolytic, fibrinolytic and haemolytic activities. In addition phage typing, crystal violet reaction, urease and galactose breakdown were studied. Seventy-one percent of isolates were enterotoxigenic. Production of SEA was significantly lower amongst the bone/joint isolates. Production of SEB, was lower among the control group compared with CAPD, bone/joint, and non-line septicaemia isolates. SEE production was higher among the bone/joint isolates compared with the CAPD and non-line septicaemias and production of TSST-1 was significantly higher among nasal isolates compared with isolates causing infection. Almost all of the isolates were lipolytic, with highest activity amongst nasal and bone/joint isolates. Fibrinolytic activity was similar in the five groups of isolates. Proteolytic activity ranged from 35 to 62% of isolates with the lowest frequency among septicaemia isolates. In all, 80-90% of isolates were haemolytic, although CAPD isolates were less likely to be haemolytic. Isolates from the control and CAPD group more frequently belonged to phage group I. TSST-1 does not appear to be an important requirement for invasive infections, but SEB may be. Proteolysis and intensity of lipolysis appear to be less important in septicaemia, and haemolysis may not be important in CAPD peritonitis.     

The history of occupational health service in Korea

Dialysate and serum levels of granulocyte-colony stimulating factor (G-CSF), granulocyte macrophage colony stimulating factor (GM-CSF) and leukemia inhibitory factor (LIF) were analyzed in patients with continuous ambulatory peritoneal dialysis (CAPD). Samples from the peritoneal effluent and from serum were obtained during the first months of dialysis and during peritonitis from the first three dialysate bags drained on the day of admittance and form nightbags on days three and ten. Serum samples were drawn on days one and ten. On the first day of infection G-CSF was detected in twelve out of fifteen samples in the dialysate and reached its peak median level, 443 pg/ml, in the first drained bag and thereafter decreased significantly. Also in serum a peak, 190 pg/ml, was observed on the first day. LIF was found in six of ten analyzed dialysate samples, with a peak median level of 77 pg/ml on day one, while only four of ten patients had detectable GM-CSF. Peripheral blood mononuclear cells from non-infected CAPD patients were stimulated with lipopolysaccharide and G-CSF levels in the supernatants increased significantly (P < 0.05) after 6 h stimulation. We conclude that G-CSF is produced locally in the dialysate during the acute stage of peritonitis and to a lesser extent also systemically. These findings are in line with G-CSF production after LPS stimulation of peripheral blood mononuclear cells.     

Prevalence and risk factors for hepatitis C virus infection in continuous ambulatory peritoneal dialysis patients

BACKGROUND: Studies on hepatitis C virus antibodies (Anti-HCV) in CAPD patients are scarce and include a small number of patients. Nevertheless, risk factors related to Anti-HCV in these patients are still subject to controversy. Purpose of the study. To analyse the incidence and risk factors associated with the presence of Anti-HCV in CAPD patients. METHODS: We studied 255 patients from five different treatment centres of our region. The analysis was repeated after excluding 161 patients who had previously received haemodialysis treatment at least once. Anti-HCV testing was made by the 2nd-generation ELISA: As a supplementary test we used RIBA-4 in three centers and INNOLIA in the other two. Risk factors were analysed using logistic regression model for multivariate analysis. RESULTS: In the whole group, 29 patients (11.4%) were anti-HCV positive. Logistic regression analysis determined the following variables as independent risk factors: hepatitis previous to CAPD (P<0.001, odds ratio (OR):44.9), Anti HBc positivity (P=0.019, OR:9. 24), blood transfusions previous to CAPD (P=0.015, OR:1.05) and CAPD duration were excluded, the prevalence of HCV antibodies was 8.5% (8/94). In this group multivariate analysis showed that Anti-HCV positivity correlated with hepatitis previous to CAPD (P<0.0003, OR: 126) and Anti HBc positivity (P=0.002, OR:41.9). CONCLUSIONS: Our prevalence of hepatitis C virus (HCV) infection in CAPD patients was lower than other renal replacement therapy modalities, and correlated to events occurring mainly before starting CAPD treatment. This technique could be considered as low risk for HCV infection.     

Intraperitoneal chemotherapy: a prolonged infusion of 5-fluorouracil using a novel carrier solution

A novel carrier solution, icodextrin 20 (7.5%) has allowed exploration of prolonged intraperitoneal (IP) infusion of the cytotoxic drug, 5-fluorouracil. Eighteen patients with intraperitoneal carcinomatosis were entered into a feasibility and pharmacokinetic study of prolonged regional (IP) chemotherapy.. Specialist nurses trained the patients to self-administer their own treatment via a permanent i.p. catheter. A twin bag delivery system was used to perform one exchange daily. It proved possible to deliver continuous (5 days per week) i.p. 5-fluorouracil at doses of 200 mg/m2 and 300 mg/m2 for up to 12 weeks. The toxicities seen were infective peritonitis, nausea and vomiting, lethargy and anorexia. This was a nurse-led study and the home-based therapy holds promise for patients with malignant peritoneal disease.     

Lipopolysaccharide-binding protein is present in effluents of patients with Gram-negative and Gram-positive CAPD peritonitis

BACKGROUND: Bacterial peritonitis is a frequent complication during treatment of end-stage renal failure by continuous ambulatory peritoneal dialysis. Local host defence mechanisms including the secretion of proinflammatory cytokines by peritoneal macrophages are of particular importance in the pathogenesis of infectious complications. LPS-binding protein (LBP) and soluble CD14 (sCD14) are serum factors known to regulate the endotoxin-induced cellular immune response. However, it is still unknown whether LBP and sCD14 are also present in the peritoneal effluent of CAPD patients. METHODS: Using specific immunoassays, we examined the concentration of LBP, sCD14 and the proinflammatory cytokines TNF-alpha, IL-1beta and IL-6 in the dialysis effluents of 31 patients with CAPD-associated peritonitis. Twenty patients without peritonitis served as controls. Intraperitoneal LPS concentrations were determined using the limulus amebocyte lysate assay. RESULTS: Bacterial lipopolysaccharide could be detected in 42% of the infected dialysis effluents. In comparison to controls (0.2 +/- 0.05 microg/ml), LBP was significantly elevated in both gram-negative/LPS-positive (1.03 +/- 0.3 microg/ml) and gram-positive infections (0.5 +/- 0.14 microg/ml) (P<0.05). No significant differences were detected concerning the intraperitoneal sCD14 levels in the three patient groups. Levels of TNF-alpha, IL-1beta and IL-6 were significantly increased in the effluents of patients with bacterial peritonitis compared to noninfected controls. Moreover the respective cytokine concentrations were significantly higher in the gram-negative/LPS-positive compared to the gram-positive bacterial infections (P<0.01). CONCLUSION: Our data demonstrate that LBP is significantly elevated in the dialysis effluents of patients with CAPD-associated peritonitis caused by both gram-negative and gram-positive bacteria and might be used as a marker of intraperitoneal infection. Moreover, our findings support the concept that LBP enhances the effects of LPS on cytokine production by peritoneal macrophages. The function of LBP in gram-positive infection remains to be further elucidated.     

Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint

PURPOSE: This study was conducted to compare the efficacy of the Er-YAG laser sclerostomy ab externo versus trabeculectomy in the treatment of primary open-angle glaucoma. METHODS: Twelve patients with POAG underwent ab externo laser sclerostomy using an Er-YAG laser (Sklerostom 2.9; lambda = 2940 nm, t = 200 microseconds, 2 Hz, 400 microns, 15 mJ). Only local medication was used, and there were no risk factors for failure. As a control group 12 patients out of 248 standardized trabeculectomies were matched in terms of age, sex, diagnosis and local medications. No antimetabolites were used in either group. RESULTS: After a follow-up of 9 months in the sclerostomy group 53%; (7/12; P = 0.03) showed a patent fistula in comparison of 100% in the trabeculectomy group. There was a significantly lower mean IOP during the first postsurgical week in the group of sclerostomies (3.6 +/- 1.5 mmHg versus 7.5 +/- 2.7 mmHg; P = 0.0001) with a higher incidence of choroidal detachments (9/12 versus 2/12; P = 0.004). The choroidal detachments lasted longer in the sclerostomy group (3.5 months versus 0.3 months; P = 0.014). Iris incarcerations were found only in sclerostomies (7/12; P = 0.05). CONCLUSIONS: Based on these findings, Er-YAG laser sclerostomy prooved to be less effective than trabeculectomy in the treatment of glaucoma patients. Er-YAG laser sclerostomies were associated with a higher incidence of postsurgical complications such as hypotony, choroidal detachments and iris incarcerations. At this point Er-YAG laser sclerostomy is not superior to conventional trabeculectomy.     

Revised cutoff values of serum aminotransferase in detecting viral hepatitis among CAPD patients: experience from Taiwan, an endemic area for hepatitis B

BACKGROUND: To determine the best cutoff values of aspartate aminotransferase (AST) and alanine amino-transferase (ALT) in detecting viral hepatitis C infection among patients of continuous ambulatory peritoneal dialysis (CAPD). METHODS: 90 (44 male and 46 female) CAPD patients and 526 adult controls (266 male, 260 female) were enrolled. Serum AST and ALT were measured by an auto-analyser monthly. Serum HBsAg was examined using a RIA method and anti-HCV by an second-generation EIA method. The best cutoff values of AST and ALT for detecting viral hepatitis were obtained from the ROC (receiver-operating characteristic) curve. RESULTS: The prevalence of anti-HCV(+) was significantly higher in CAPD patients (16.7%) than in normal controls (4.9%), while that of HBsAg(+) was similar in both groups. CAPD patients had significantly lower levels of serum aminotransferases compared to normal controls. Mean AST were 23.8 IU/l in normal control and 18.8 IU/l in the CAPD patients (P < 0.001). Mean ALT were 21.9 IU/l in normal controls and 15.3 IU/l in the CAPD patients (P < 0.001). CAPD patients with HCV infection had higher serum AST and ALT levels than those without. However, HBV infection did not cause significant serum aminotransferase elevation in patients. The conventional cutoff values of AST (40 IU/l) and ALT (40 IU/l) for detecting viral hepatitis yielded only a sensitivity of 27.3 and 18.2% respectively; on the contrary, our revised cutoff values of AST (24 IU/l) and ALT (17 IU/l) had better sensitivities (AST, 72.7%; ALT, 63.6%). For serial aminotransferase values, the sensitivity of AST and ALT for detecting HCV were 36.4 and 27.3% by conventional criteria, and were both 81.8%, by our newly revised criteria. CONCLUSIONS: Serum aminotransferase cutoff values should be modified for screening viral hepatitis in a CAPD population. Our new cutoff criteria had important clinical implications in providing benefits of earlier detection and possible prevention from chronic hepatic deteriorations.