Gandhi Vc

Peritoneal Sclerosis in Peritoneal Dialysis Patients

Peritoneal sclerosis, a disorder similar to that previously identified in nonuremic patients, is being noted in peritoneal dialysis patients with increasing frequency. The etiology in dialysis patients remains unknown. An association with previous or ongoing peritoneal inflammation or irritation suggests that the incidence of peritoneal sclerosis could be reduced by rapidly controlling peritonitis and by eliminating the irritant properties of catheters, dialysate, and other materials used in performing peritoneal dialysis. If peritoneal sclerosis does supervene, weight loss, abdominal pain, and intestinal obstruction may occur and further peritoneal dialysis may become impossible because of abdominal pain or poor fluid and solute transfer.

Failure of Peritoneal Dialysis Due to Peritoneal Sclerosis

Sir, Peritoneal sclerosis, otherwise known as sclerosing peritonitis or encapsulating peritonitis, has recently been described in patients treated with intermittent peritoneal dialysis (IPD) or continuous ambulatory peritoneal dialysis (1-3). The disorder is characterized by the deposition of a dense layer of fibro-connective tissue on the peritoneal membrane. When advanced, a sclerotic cocoon may form and cause encasement, constriction and shortening of small bowel loops (1,4). Clinically, affected patients may present with asthenia, weight loss, abdominal pain or abdominal mass. Small bowel obstruction may also occur (4). . In the past several years, we have encountered 7 patients with IPD-associated peritoneal sclerosis, diagnosed either at laparotomy or autopsy (1, 5). In 3 of the patients, peritoneal dialysis had to be discontinued because of persistent abdominal pain. The remaining 4 patients had impairment of peritoneal clearance to an extent that peritoneal dialysis was no longer effective. In 2 of these, we were able to perform sequential peritoneal clearance measurements: once before the onset of peritoneal sclerosis and once within a week after establishment of the lesion at laparotomy (Table).

Increasing plasma phosphorus values by enriching with phosphorus the "acid concentrate" of a bicarbonate-buffered dialysate delivery system.

Each of seven hypophosphatemic hemodialysis patients was dialyzed with a phosphorus-enriched, bicarbonate-buffered dialysate. The latter was prepared by the introduction of sodium phosphate salts to the “acid concentrate” of a bicarbonate-buffered dialysate delivery system. The patients tolerated the procedure well and their hypophosphatemia improved.

Bicarbonate-Buffered Peritoneal Dialysis

Although relatively difficult to prepare and store, sterile peritoneal dialysis solutions containing bicarbonate, calcium and magnesium may at times be needed (1-10), For example, one may have to dialyze a uremic patient who has developed hypotension and lactic acidosis, In such a patient, the lactate or acetate in conventional dialysates may not be metabolized to bicarbonate because of tissue hypoxia, and acidosis may be further worsened because bicarbonate is removed during dialysis (11-14). Using bicarbonate-containing dialysate in such a patient will add bicarbonate to the blood and also remove lactate (12-14). For these reasons, some authors have recommended bicarbonate-buffered peritoneal dialysis as adjunctive treatment for severe lactic acidosis (13). Another potential application may be for patients who experience abdominal pain or discomfort when conventional acetateor lactate-buffered peritoneal dialysates are infused. The abdominal pain may be related to the unphysiologically high acidity [e.g., with a pH as low as 5.2 (15)] of acetateand lactate-buffered dialysates (16). Conceivably, bicarbonate-buffered peritoneal dialysate, with its more physiologic pH, might decrease the incidence of such symptoms. Since the basic principles for preparing bicarbonatebuffered dialysate for peritoneal dialysis are the same as those for hemodialysis, a brief review of methods to prepare bicarbonate-buffered hemodialysate is in order.

Peritoneo-Venous Shunting in Patients With Cirrhotic Ascites and End-Stage Renal Failure

End-stage renal failure supervened in two cirrhotic patients with ascites, necessitating maintenance hemodialysis therapy. One patient had a functioning LeVeen peritoneo-jugular shunt (Becton-Dickinson, Rutherford, NJ) in place at the time that hemodialysis was initiated. In the other patient, a LeVeen shunt was inserted 8 months after beginning hemodialysis, after extracorporeal ultrafiltration had failed to resolve his ascites. Both patients achieved control of their ascites and enjoyed relatively long survival. Our results suggest that, in patients with cirrhotic ascites who develop end-stage renal failure, successful long-term management can be obtained using a combination of peritoneo-venous shunting and maintenance hemodialysis.

Peritoneal sclerosis in continuous ambulatory peritoneal dialysis patients dialyzed exclusively with lactate-buffered dialysate.

Peritoneal sclerosis occurred in two patients treated by continuous ambulatory peritoneal dialysis (CAPD) using only lactate-buffered dialysate. Both patients had recurrent peritonitis and the second patient had multiple, minor abdominal operations. Patients receiving lactate-buffered CAPD are not immune from peritoneal sclerosis. Recurrent peritonitis and repeated abdominal surgery might be important causative factors.

Pyocystis in a renal transplant recipient with a defunctionalized bladder.

Fever occurred in a man 6 weeks after renal transplantation. At the time of transplantation, the donor ureter had been anastomosed to a ureteroileal conduit created 6 years previously because of traumatic neurogenic bladder. Initial evaluation failed to reveal the cause of the fever, but ultimately, drainage of the defunctionalized bladder yielded a large amount of pus infected with Klebsiella pneumoniae. Our patients course suggests that, when fever develops after renal transplantation in patients with previous urinary diversion, pyocystis should be included in the differential diagnosis.

Continuous ambulatory peritoneal dialysis using self-made, ultrafiltration-sterilized, L-lactate-based dialysis solution

Continuous ambulatory peritoneal dialysis was successfully carried out in 6 end-stage renal failure patients using self-made, ultrafiltration-sterilized dialysis solutions. A Y-set was used to deliver the above solutions to sterile plastic bags.