Ana Rodríguez-Carmona

Treatment of Staphylococcus aureus Nasal Carriers in Continuous Ambulatory Peritoneal Dialysis With Mupirocin: Long-term Results

We present the clinical results of a prospective protocol of the treatment of Staphylococcus aureus nasal carriers (SANCs) in our continuous ambulatory peritoneal dialysis unit with mupirocin (Bactroban, SmithKline Beecham Pharmaceuticals, Philadelphia, PA). We monitored the incidence of peritonitis and catheter exit-site infection, the rate of infection-related catheter loss, and the degree of association between SANC state and S aureus infection. The study group included 94 patients with a follow-up of 1,097 patient-months (phase B). The same information was retrospectively collected among 74 continuous ambulatory peritoneal dialysis patients treated during the 24 months preceding the study period (follow-up of 1,043 patient-months) (phase A). S aureus nasal carriage was observed in 47.5% of the patients. Mupirocin was very effective in eradicating S aureus from the nares, but most patients required periodic retreatment. The incidence of S aureus peritonitis decreased from 1 episode/58 patient-months in phase A to 1 episode/548 patient-months in phase B, and the incidence of exit-site infection decreased from one episode/55 patient-months in phase A to 1 episode/137 patient-months in phase B. However, there was a simultaneous increase in the incidence of infections by other gram-positive and -negative bacteria. The rate of catheter loss after peritonitis (P = not significant) or exit-site infection (P < 0.05) tended to decrease from phase A to phase B. Seventy-seven percent of the peritonitis infections and 74% of the exit-site infections by S aureus occurred in SANCs.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperleptinemia in uremic patients undergoing conservative management, peritoneal dialysis, and hemodialysis: A comparative analysis

We performed a cross-sectional study in a wide sample of patients with chronic renal failure undergoing conservative therapy (CTh) (n = 79), peritoneal dialysis (PD) (n = 75), and hemodialysis (HD) (n = 51), with the aim of analyzing the impact of the different modes of therapy on serum leptin levels. We used a multivariate approach, taking into consideration the potential effects of other epidemiological, dialysis-related, nutritional, and hormonal factors on serum leptin. Leptin levels were higher in patients treated with PD (median, 36 ng/mL) than in those undergoing CTh (10.8 ng/mL) or HD (5.4 ng/mL) (P < 0.0005). This difference persisted after controlling for gender, body mass index, and fasting insulin levels, suggesting that imbalances in these factors may only partially explain the differences found between the three modes of therapy. Leptin levels showed a significant negative correlation with peritoneal protein losses in PD patients but were poorly associated with factors such as proteinuria, daily peritoneal glucose absorption (PD), renal function, or adequacy of dialysis. Leptin and insulin-like growth factor-I (IGF-I) were significantly correlated in PD patients, but the study design did not allow for establishing a meaning for this correlation. In conclusion, serum leptin levels are increased in PD patients when compared with CTh or HD patients. Differences in gender distribution, fat mass, and insulin levels may partially explain these findings, but other undefined factors also may have a role in producing these results.

EARLY PROTEINURIA IN RENAL TRANSPLANT RECIPIENTS TREATED WITH CYCLOSPORIN

PURPOSEnTo establish the risk profile for the development of proteinuria in the first months after renal transplantation and to disclose the prognostic significance of this finding.nnnDESIGNnWe conducted an observational historic cohort study.nnnSETTINGnWe conducted the study in a tertiary care hospital renal transplantation unit covering a potential population of approximately 2 million. We made extensive use of suboptimal donors.nnnPOPULATIONnIn our unit, 560 cadaveric renal transplants were performed between January 1988 and June 1997, under Cyclosporine immunosuppression, with a minimum follow up of 1 year.nnnMETHODnThe risk profile analysis explored early clinical factors reported to be related to the late course of renal transplantation. The study of the prognostic significance of proteinuria included survival analysis and correlation with late markers of graft dysfunction, taking into consideration the intensity and persistence of early proteinuria. A multivariate approach was used in all cases.nnnRESULTSnEarly proteinuria was strongly associated with delayed graft function (odds ratio [OR] 1.03/day of dialysis), acute rejection (OR 1.7 for steroid-sensitive and 6.2 for steroid-resistant rejection), renal transplant to a hypersensitized recipient (OR 2.5), and pediatric (<5 years)(OR 4.1) or older (>60 years)(OR 3.0) donors. The predictive model for persistency of proteinuria was very similar, whereas transient proteinuria could not be adequately modeled. Increasing intensity of proteinuria was strongly associated with poor patient and graft survival. Persistent, but not transient, proteinuria supported this relationship.nnnCONCLUSIONSnProteinuria appearing early after renal transplantation is strongly associated with delayed graft function, acute rejection, and the use of pediatric or older donors. Whatever its background, proteinuria is a strong predictor of poor patient and graft survival. This effect is directly related to the intensity and persistence of the disorder.

Early immunologic and nonimmunologic predictors of arterial hypertension after renal transplantation

We followed up a cohort of 680 renal transplant recipients receiving cyclosporine (CsA) immunosuppression with the aim of establishing an early-risk profile for early and late hypertension (HT) after renal transplantation (RTx), specifically comparing the predictive role of immunologic and nonimmunologic markers of graft prognosis. HT was defined as the need for antihypertensive drugs. The prevalence of HT was 65% at the time of RTx, increased to a peak of 78% at the end of the first year, and stabilized between 71% and 73% thereafter. Multivariate analysis identified HT at the time of RTx, basal renal disease, and grafting the right kidney as independent predictors of HT 3 months after RTx. The risk profile for HT 12 months after RTx included HT present at RTx, grafting the right kidney, markers of early ischemia-reperfusion injury (delayed graft function, cold and warm ischemia), and transplant from an elderly or female donor. Polytransfusion before RTx was associated with a decreased risk for HT, but retransplantation, increased reactivity against the lymphocyte panel, poor HLA compatibility, and early acute rejection did not portend an increased risk for the complication under study. The CsA schedule (dose, trough levels) correlated poorly with the blood pressure status of the patients, but simultaneous graft function was independently associated with late HT. In conclusion, the early predictive profile for HT after RTx includes, preferentially, nonimmunologic markers of graft prognosis. Hyperfiltration damage may be a significant pathogenic mechanism for this complication of RTx.

Hyperleptinemia is not correlated with markers of protein malnutrition in chronic renal failure: A cross-sectional study in predialysis, peritoneal dialysis and hemodialysis patients

Background: Serum leptin levels are increased in chronic renal failure (CRF) and may potentially contribute to protein malnutrition in this disorder. Method: Following a cross-sectional design, we performed a nutritional survey in a wide sample of uremic patients treated conservatively (n = 87), with peritoneal dialysis (n = 71) and with hemodialysis (n = 53). Then, we analyzed the correlation between serum leptin levels and markers of protein malnutrition. We used a multivariate approach, taking into consideration the confounding effect of other factors on the correlation between hyperleptinemia and protein malnutrition. Main Results: Both univariate and multivariate analysis disclosed a poor correlation between hyperleptinemia and markers of protein malnutrition. In fact, there were trends to a positive correlation between leptinemia and body protein stores, as estimated from the scrutinized markers. Persistence of the basic correlation between general intake, fat mass and leptin in CRF could partially explain these findings, but neither a negative correlation between leptin levels nor protein nutritional state could be disclosed after controlling for this factor. Conclusions: Our results do not support a first-line role for hyperleptinemia in the genesis of protein malnutrition of uremia.

Chylous ascites associated with acute pancreatitis in a patient undergoing continuous ambulatory peritoneal dialysis

We report on a case of chylous ascites associated with acute pancreatitis secondary to gallbladder stone disease, in a patient undergoing continuous ambulatory peritoneal dialysis. The initial clinical presentation was one of bacterial peritonitis, with later appearance of chylous peritoneal drainage. Diagnosis was suggested by abdominal computed tomography and confirmed by surgical exploration. We discuss the main diagnostic keys of peritoneal dialysis-associated pancreatitis and the possible etiologic role of this entity in chylous ascites of these patients.

Correlation Between Glycemic Control and the Incidence of Peritoneal and Catheter Tunnel and Exit-Site Infections in Diabetic Patients Undergoing Peritoneal Dialysis

♦ Background: Diabetes mellitus, especially if complicated by poor glycemic control, portends an increased risk of infection. The significance of this association in the case of diabetic patients undergoing peritoneal dialysis (PD) has not been assessed. ♦ Methods: Using a retrospective observational design, we analyzed the association between glycemic control at the start of PD (estimated from glycosylated hemoglobin levels) and the risk of peritoneal and catheter tunnel and exit-site infections during follow-up in 183 incident patients on PD. We used the median value of glycosylated hemoglobin to classify patients into good (group A) or poor (group B) glycemic control groups. We applied multivariate strategies of analysis to control for other potential predictors of PD-related infection. ♦ Results: Groups A and B differed significantly in age, dialysis vintage, use of insulin, and rate of Staphylococcus aureus carriage. Neither the incidence (0.60 episodes in group A vs 0.56 episodes in group B per patient-year) nor the time to a first peritoneal infection (median: 42 months vs 38 months) differed significantly between the study groups. In contrast, group B had a significantly higher incidence of catheter tunnel and exit-site infections (0.23 episodes vs 0.12 episodes per patient-year) and shorter time to a first infection episode (64 months vs 76 months, p = 0.004). The difference persisted in multivariate analysis (adjusted hazard ratio: 2.65; 95% confidence interval: 1.13 to 6.05; p = 0.013). We observed no differences between the study groups in the spectrum of causative organisms or in the outcomes of PD-related infections. ♦ Conclusions: Poor glycemic control is a consistent predictor of subsequent risk of catheter tunnel and exit-site infection, but not of peritoneal infection, among diabetic patients starting PD therapy.

Aspergillus Peritonitis Complicating Continuous Ambulatory Peritoneal Dialysis

Dr. M. Pérez-Fontán, Servicio de Nefrología, Hospital Juan Canalejo, Xubias de Arriba 84, E-15006 A Coruña (Spain) Dear Sir, Fungal peritonitis represents one of the most feared complications of continuous ambulatory peritoneal dialysis (CAPD), given its significant mortality, and the frequent impossibility for continuation of peritoneal dialysis in survivors [1]. Most of these infections are caused by different yeasts of the species Candida [1,2], but the list of fungi causing peritonitis in CAPD is continuously expanding [1]. Filamentous fungi of the species Aspergillus are a rare cause of peritonitis in CAPD, seemingly producing particularly severe infections, with a high mortality rate [3–5]. We report on a case of Aspergillus peritonitis complicating CAPD, with a rapid favorable course once the peritoneal catheter was removed, even in the absence of effective antifungal therapy. The patient could reas-sume CAPD 2 months later, with a well-preserved peritoneal function and no evidence of relapse to date. Case Report A 69-year-old white male, with severe coronary heart disease and nephroangiosclerosis-related chronic renal failure, was started on CAPD in September 1987. During the following 2 years, his clinical course was complicated by severe relapsing angina pectoris, which markedly limited his physical activity, leading to inadequate rehabilitation and progressive obesity. The patient presented no episode of peritonitis or catheter exit-site or tunnel infection during this period. On December 4,1989, the patient experienced the sudden onset of fever, diffuse abdominal pain and, subsequently, cloudy dialysate effluent. He was evaluated on an ambulatory basis the same day. The most relevant findings on physical examination were: stable hemodynamic situation, febricula (37.5 °C), diffuse abdominal tenderness, and a noninflammated catheter exit-site. The dialysis effluent was cloudy, containing 1,940 cells/mm3 (43% polymor-phonuclear leukocytes, 32% histiocytes, 14% lymphocytes and 11% eosinophils). Dialysate samples were obtained for microbiological study, and therapy with intraperitoneal ciprofloxacin (50 mg/l dialysate) was begun. Abdominal pain, febricula and cloudy dialysate persisted, and the patient was admitted on the 4th day of evolution. The next day, fungal growth on a dialysate sample was detected; ciprofloxacin was discontinued, and intraperitoneal am-photericin (2 mg/l dialysate) and oral ketoconazol (200 mg b.i.d.) were begun. Subsequently, four samples of dialysate (days 1–5) grew Aspergillus sp. On the 10th day, and due to lack of response to antifungal therapy, the

Avances recientes y perspectivas futuras en diálisis peritoneal

Resumen Tras desarrollarse durante los ultimos 25 anos del pasado siglo, la dialisis peritoneal afronta en el presente 2 grandes desafios: consolidarse como opcion inicial de tratamiento sustitutivo renal y optimizar sus resultados a largo plazo en cuanto a supervivencia de tecnica y pacientes, con el fin de equipararse plenamente a la hemodialisis. El primer objetivo demandara la asimilacion por parte de la comunidad nefrologica del concepto de tratamiento integrado de la uremia, que contempla las distintas modalidades de tratamiento sustitutivo como opciones complementarias, y en ningun caso competitivas. Tambien sera necesaria la generalizacion de la eleccion informada por parte de los pacientes respecto a sus opciones de tratamiento, un objetivo que ha de cumplirse en unidades especificas de atencion a enfermos con insuficiencia renal cronica avanzada. La mejoria en los resultados de la dialisis peritoneal a largo plazo pasara, con toda probabilidad, por 3 mecanismos. En primer lugar, las mejoras en la biocompatibilidad de las soluciones de dialisis y en la prevencion de peritonitis ayudaran a preservar la membrana peritoneal. En segundo lugar, los objetivos de adecuacion deberan redefinirse en los proximos anos, con especial atencion al control del volumen extracelular. Por ultimo, las mejoras en la adaptacion de las tecnicas domiciliarias a las condiciones sociales y laborales de cada caso permitiran, sin duda, optimizar la calidad de vida de los pacientes.