Elaine J. Clutterbuck

Assessing the Validity of an Abdominal CT Scoring System in the Diagnosis of Encapsulating Peritoneal Sclerosis

BACKGROUND AND OBJECTIVESnEncapsulating peritoneal sclerosis (EPS) is a severe peritoneal fibrotic reaction in patients on long-term peritoneal dialysis (PD). The early clinical features may be nonspecific. The purpose of the study is to assess the reliability and diagnostic utility of abdominal CT scanning in the diagnosis of EPS.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnAbdominopelvic CT scans of 27 patients diagnosed with EPS on clinical and radiologic grounds in our unit from 1997 to 2006 were retrospectively analyzed. In addition, 35 control CT scans were scored: 15 from hemodialysis patients (HD controls) and 20 from patients on PD (PD controls). Scans were anonymized and scored independently by three radiologists.nnnRESULTSnInter-rater agreement was moderate to very good (kappa = 0.40 to 0.75) for peritoneal calcification, bowel distribution, bowel wall thickening, and bowel dilation but poorer for loculation of ascites and peritoneal thickening. There was a strongly significant difference between the total CT scan scores at EPS diagnosis and controls (P < 0.00001). Each individual parameter also showed significant differences between EPS and controls (P < 0.006). Bowel tethering and peritoneal calcification were the most specific parameters, and. loculation was the least discriminatory parameter. Interestingly, prediagnostic scans a median of 1.5 yr before EPS diagnosis were normal or near-normal in 9 of 13 EPS patients.nnnCONCLUSIONSnCT scanning is a valid and reliable adjunct to the diagnosis of EPS but may not be useful as a screening tool, as the prediagnostic scans did not show abnormalities in many patients who subsequently developed EPS.

Reducing dialysis associated bacteraemia, and recommendations for surveillance in the United Kingdom: prospective study.

Abstract Problem Bacteraemia in dialysis units accounts for major morbidity, mortality, and antibiotic usage. Risk is much greater when lines rather than fistulas are used for haemodialysis. Surveillance is critical for infection control, but no standardised surveillance scheme exists in the United Kingdom. Design Prospective study in a London dialysis unit of the implementation and applicability of a dialysis associated bacteraemia surveillance scheme developed in the United States and its effect on bacteraemia, antibiotic usage, and admission. Setting Hammersmith Hospital dialysis unit, London, where 112 outpatients receive dialysis three times weekly. Between June 2002 and December 2004, 3418 patient months of data were collected. Key measures for improvement Successful adoption of the scheme and reductions in bacteraemia rates, antibiotic usage, and admission to hospital. Strategy for improvement Embedding the surveillance scheme in the units clinical activity. Effects of change Raised awareness of bacteraemia prevention, prudent antibiotic prescribing, and the need for improved provision of vascular access. The scheme required two hours a month of consultant time. Significant downward trends were seen in bacteraemia rates and antibiotic usage: mean rate ratios from quarter to quarter 0.90 (95% confidence interval 0.85 to 0.94) and 0.91 (0.87 to 0.96), respectively. The rate of admission to hospital also showed a significant downward trend, with admissions directly connected to access related infection declining more rapidly: mean rate ratio of successive quarters 0.90 (0.84 to 0.96). The overall proportion of patients dialysed through catheters was significantly higher than in US outpatient centres (62.3% v 29.4%, P < 0.01). Study data were successfully used in a business case to improve access provision. Lessons learnt Dialysis specific surveillance of bacteraemia is critical to infection control in dialysis units and improving quality of care. Such a scheme could be adopted across the United Kingdom.

Bullous dermatoses in end-stage renal failure: Porphyria or pseudoporphyria?

Bullous dermatoses (BD) are well recognized in patients with end-stage renal disease (ESRD). It is important to distinguish pseudoporphyria (porphyrin accumulation due to decreased clearance) from true porphyrias, particularly those in which acute neurological attacks may occur. Investigation of the dialysis patient poses practical diagnostic difficulties because urinary porphyrin profiles are not available. We describe a patient on continuous ambulatory peritoneal dialysis (CAPD) with several recognized causative factors for porphyria cutanea tarda (PCT). The patient presented with a blistering photosensitive rash. We highlight the importance of investigating anuric patients with fractionation of both fecal and plasma porphyrins. Plasma porphyrins were grossly elevated (345 nmol/L; reference range, <13), whereas plasma porphyrins in a control group of CAPD patients without blistering rashes were only minimally elevated (mean, 23.9 nmol/L; SD, 11.0; n = 9). Fractionation of fecal porphyrins by high-performance liquid chromatography (HPLC) yielded a pattern typical of PCT. In addition to the contributory factors for PCT that were present, it is possible that porphyrin accumulation secondary to renal failure played a role in the expression of her disease. Patients with ESRD presenting with BD require careful evaluation, including fractionation of fecal porphyrins.

Lesson of the week: cholesterol emboli syndrome.

Cholesterol embolism is a common but underrecognised complication arising from a variety of vascular insults

Retropharyngeal Infection with Staphylococcus aureus in a Haemodialysis Patient

The case of a 55-year-old female Asian haemodialysis patient is described. She developed a septicaemic illness and retropharyngeal soft-tissue infection secondary to Staphylococcus aureus infection.