Jack Rubin

An Autopsy Study of the Peritoneal Cavity From Patients on Continuous Ambulatory Peritoneal Dialysis

Sixteen autopsies were performed on patients aged 56 +/- 15 (SD) years who were on continuous ambulatory peritoneal dialysis (CAPD) for 834 +/- 766 (SD) days. Lactate-buffered dialysate and povidone-iodine antiseptic were used in all cases. Multiple peritoneal sections were taken to evaluate peritoneal membrane thickening, inflammation, neovascularization, fibrosis, and adhesions. Peritoneal thickening, inflammation, or adhesions were not related to sex, race, or etiology of renal failure. Time on dialysis was also not a direct determinant of peritoneal adhesions or neovascularization. Peritonitis episodes correlated with chronic peritoneal serosal changes. This study supports the hypothesis that peritoneal alterations in patients on CAPD are related to episodes of peritonitis.

Measurements of Peritoneal Surface Area in Man and Rat

The peritoneal dialysis system is composed of unique membranes. To better understand the contribution of these membranes to peritoneal transport, the peritoneal surface areas were measured in human subjects and rats.

Peritoneal Abnormalities during Infectious Episodes of Continuous Ambulatory Peritoneal Dialysis

Exchanges were performed in 1-hour and 3- to 5-hour cycles when patients were noninfected and during episodes of peritonitis. The hourly exchange dialysate effluent volume decreased with the occurrence of peritonitis. These exchanges were associated with increased glucose absorption from dialysate, diminished sodium removal and augmented clearances of urea and creatinine. Protein losses were increased in the dialysate effluent of patients during an episode of peritonitis during the hourly exchanges. In the long-dwell exchanges obtained after clinical improvements of peritonitis, only protein losses were increased over control. Clearances, sodium loss in dialysate and glucose absorption were not altered from control.

Fungal Peritonitis During Continuous Ambulatory Peritoneal Dialysis: A Report of 17 Cases

Seventeen cases of fungal peritonitis and one case of Nocardia asteroides peritonitis were observed in 141 patients during the first 5 years of our continuous ambulatory peritoneal dialysis program (CAPD). Fungal peritonitis accounted for 7% of the episodes of peritonitis observed in this interval. There were eight deaths associated with fungal peritonitis. In only three instances could factors predisposing to fungal peritonitis be identified. We were unable to predict who would develop fungal peritonitis by analysis of nutritional, demographic, or technical factors associated with the dialysis procedure. The diagnosis of fungal peritonitis was easily established using routine blood agar culture techniques. Successful management of these patients included prompt removal of the Tenckhoff catheter and intravenous (IV) administration of amphotericin.

The Tenckhoff Catheter for Peritoneal Dialysis – An Appraisal

We prospectively evaluated early (within 40 days) catheter complications in all patients receiving a dialysis catheter between 1/8/80 and 1/8/81. 50% of patients achieved a functioning catheter at the first insertion and 24% required replacement of the catheter because of poor dialysate flow. Leaking from the catheter exit site occurred in 20%, infection at the exit site in 9% and peritonitis in 19% of patients. In patients who maintain a catheter over 40 days and undergo treatment by long-term peritoneal dialysis median catheter survival was 400 days with delayed cytheter failure primarily due to failure to resolve a clinical episode of peritonitis. Although the Tenckhoff catheter is readily inserted frequent complications occur.

Peritonitis in Continuous Ambulatory Peritoneal Dialysis Patients

Peritonitis is the most important complication of continuous ambulatory peritoneal dialysis (CAPD). We reviewed our experience with peritonitis over a 2 1/2-year period. Our patients spent 4% of their total time on dialysis in hospital due to peritonitis. Thirty-eight percent of the episodes of peritonitis were treated without hospitalization. We evaluated the dialysate bag change technique as commonly performed with currently available devices (extension tubing and titanium Luerlock Tenckhoff catheter adapter). The aseptic techniques described for dialysis extension tubing changes appear adequate (with no increased incidence of peritonitis demonstrated shortly after an extension tubing set change). Long-term sterility is maintained at the dialysate bag puncture port and at the orifice of the dialysis catheter adapter (no positive cultures from the bag port and orifice of the titanium adapter). Etiologic diagnosis of uremia was not a risk factor predisposing to peritonitis. The incidence of peritonitis was greater among patients with less formal education and lower income. Out data suggest that patients with less formal education and of lower economic status be carefully evaluated before commencing CAPD.

Cardiac tamponade in primary myxedema and review of the literature.

A case of cardiac tamponade secondary to primary myxedema is described. The nature of the patients pericardial fluid and clinical course compared with other cases in the literature is reviewed. The patient had no recurrence of cardiac tamponade. Complete resolution of the pericardial effusion occurred 10 months followint initial pericardiocentesis and L-thyroxine therapy.

Stereospecific Lactate Absorption during Peritoneal Dialysis

Patients undergoing peritoneal dialysis were studied to determine if peritoneal absorption was selective. Dialysis was performed using dialysate exchange schedules similar to those for intermittent peritoneal dialysis and continuous ambulatory peritoneal dialysis. The clearance rate from the peritoneal cavity during hourly dialysate exchanges was 6.2 ml/min for D (-)-lactate and 8.7 ml/min for L(+)-lactate (p less than 0.01). L(+)-Lactate disappeared more rapidly from the dialysate during the long-cycle exchanges. Our results suggest that clearance of lactate from the peritoneal cavity is relatively stereospecific and raises the question of selective absorption for other organic anions.

Survival on dialysis therapy: one center's experience.

Patient survival while undergoing renal replacement therapy was evaluated from January 1, 1967, through June 15, 1986. There were 1,216 patients, of which 230 were treated by continuous ambulatory peritoneal dialysis (CAPD), 150 by home hemodialysis (HHD), and the remainder by dialysis in a free-standing dialysis facility (LCD). Covariate analysis found that patient survival on dialysis therapy was not influenced by race, sex, or marital status. Patients more than 60 years of age and patients with renal failure secondary to diabetes mellitus or hypertension had the worst survival on dialysis. Patients entering into CAPD were associated with diminished survival when compared to HHD but not to LCD. The ability of the initial dialysis technique to maintain a person on dialysis was not different when patients were matched for age, race, and etiology of renal failure. Only a randomized prospective trial will answer the question as to whether continuous ambulatory peritoneal dialysis can maintain a patient at home as long as home hemodialysis.

Evaluation of Continuous Ambulatory Peritoneal Dialysis

This study was undertaken to ascertain whether 19 patients maintained on continuous ambulatory peritoneal dialysis (CAPD) for at least 1 year experienced any deterioration in peritoneal membrane function. Selected serum chemistries and skinfold measurements were also evaluated to determine whether patients dialyzed by CAPD could maintain a normal nutritional status. This study demonstrates that patients maintained on CAPD had stable dialysate protein losses, glucose absorption from the dialysate, and constant urea, creatinine, and sodium removal. When these patients were subdivided by incidence of peritonitis, the group with a lower incidence of peritonitis (one episode every 349 +/- 155 SEM days) showed stable serum protein concentration and improvement in upper arm area whereas the group with a high incidence of peritonitis (one episode every 95 +/- 7 SEM days) showed a reduction in upper arm muscle area. Thus, our data suggest that over a 1-year period, there is no deterioration in peritoneal membrane characteristics and CAPD is effective in maintaining the nutritional status of the patient. However, both membrane function and nutritional status may be impaired by frequent episodes of infection.