María Eugenia Sanhueza

Outbreak of Paecilomyces variotii Peritonitis in Peritoneal Dialysis Patients after the 2010 Chilean Earthquake

Fungal peritonitis (FP) accounts for 3 - 6% of all peritonitis episodes in chronic peritoneal dialysis (PD), being associated with high morbidity and mortality. Mortality rates are in the range of 15 - 50%, and loss of the peritoneal membrane function can be over 40% (1). The most common cause of the disease is Candida species (C. albicans, C. parapsilosis, C. glabrata). Other yeasts and filamentous fungi such as Aspergillus, Paecilomyces, Penicillium, and Zygomycetes are found less frequently. The strongest risk factors for FP in PD patients are prolonged use of antibiotics and previous bacterial peritonitis (2). Other suggested risk factors are immunosuppression, malnutrition, bowel perforation, diverticulitis, and, possibly, certain comorbidities such as diabetes or neoplastic diseases (1). Paecilomyces spp is a filamentous fungus like the genus Penicillium and Aspergillus. It is found in soil and water and is one of the main dwellers of house dust. It is rarely associated with human infections. When a disease does occur, it is more often related to foreign bodies or immunosuppressed patients (3,4). After the earthquake of February 27, 2010, in Chile, there was an increase in the rate of FP from 1% to 6%, due to the appearance of 6 cases caused by Paecilomyces variotti (5). Here we describe the clinical characteristics and outcomes of 3 of these patients. Although there was no proof of the precise route of infection in our patients, in all 3 cases there was a major alteration in the storage of the PD fluid bags, resulting especially in exposure to excessive dust and destruction of the architecture of the storage holds. It is quite possible that in the context of a natural disaster like a big earthquake, the risk of infections associated with this fungus could increase because of the excessive dust in the environment.

Diabetes y hemodiálisis. Caracterización de una cohorte y seguimiento a cuatro años

BACKGROUND Despite a better management of the variables that influence the development of diabetic nephropathy there is a progressive increase in the prevalence of terminal renal failure among diabetics, whose cause is not clear. AIM To study in a group of patients in hemodialysis, the quality of diabetes control previous to the entry to dialysis, their physical condition and their evolution. MATERIAL AND METHODS Diabetic patients with at least three months of hemodialysis answered a questionnaire about diabetes control quality previous to dialysis and had physical and laboratory assessment. They were followed for at least four years thereafter. RESULTS Fifty seven patients aged 62+/-11 years were studied. Eighty four percent had some degree of disability. Eighty seven percent had high blood pressure and 73% had to enter dialysis as an emergency. Mean glycosilated hemoglobin was 7.7% and 58% had a dialysis dose with a Kt/Vofless than 1.2. Fifty eight percent died during follow up. No relationship between mortality and age, blood pressure, glycosilated hemoglobin of Kt/V, was observed. CONCLUSIONS There is an inadequate management of blood glucose and blood pressure of diabetic patients before entry to dialysis. They are referred inverted exclamation markate to the nephrologist, the dialysis dose is insufficient and they have a high mortality.

Diálisis con albúmina MARS (Molecular Adsorbent Recirculating System) como puente para el trasplante hepático en insuficiencia hepática fulminante: presentación de 3 casos

The most successful therapy for acute liver failure is liver transplantation. However, due to the low number of donors, organ support therapies need to be used as a bridge to liver transplantation. Molecular Adsorbents Recirculating System (MARS) is a dialysis treatment that uses a recirculating dialysate containing albumin. This allows the removal of both hydrosoluble and albumin-related substances. This system improves hepatic encephalopathy, renal dysfunction and some clinical parameters in acute liver failure, but there is no clear decrease in mortality. We report three women aged 23, 21 and 61 years, that were subjected to liver transplantation, in whom this therapy was successfully used.The most successful therapy for acute liver failure is livertransplantation. However, due to the low number of donors, organ support therapies need to be usedas a bridge to liver transplantation. Molecular Adsorbents Recirculating System (MARS) is a dialysistreatment that uses a recirculating dialysate containing albumin. This allows the removal of bothhydrosoluble and albumin-related substances. This system improves hepatic encephalopathy, renaldysfunction and some clinical parameters in acute liver failure, but there is no clear decrease inmortality. We report three women aged 23, 21 and 61 years, that were subjected to livertransplantation, in whom this therapy was successfully used (Rev Med Chile 2004; 132: 601-7).(

Human peritoneal mesothelial cell death induced by high-glucose hypertonic solution involves Ca2+ and Na+ ions and oxidative stress with the participation of PKC/NOX2 and PI3K/Akt pathways

Chronic peritoneal dialysis (PD) therapy is equally efficient as hemodialysis while providing greater patient comfort and mobility. Therefore, PD is the treatment of choice for several types of renal patients. During PD, a high-glucose hyperosmotic (HGH) solution is administered into the peritoneal cavity to generate an osmotic gradient that promotes water and solutes transport from peritoneal blood to the dialysis solution. Unfortunately, PD has been associated with a loss of peritoneal viability and function through the generation of a severe inflammatory state that induces human peritoneal mesothelial cell (HPMC) death. Despite this deleterious effect, the precise molecular mechanism of HPMC death as induced by HGH solutions is far from being understood. Therefore, the aim of this study was to explore the pathways involved in HGH solution-induced HPMC death. HGH-induced HPMC death included influxes of intracellular Ca2+ and Na+. Furthermore, HGH-induced HPMC death was inhibited by antioxidant and reducing agents. In line with this, HPMC death was induced solely by increased oxidative stress. In addition to this, the cPKC/NOX2 and PI3K/Akt intracellular signaling pathways also participated in HGH-induced HPMC death. The participation of PI3K/Akt intracellular is in agreement with previously shown in rat PMC apoptosis. These findings contribute toward fully elucidating the underlying molecular mechanism mediating peritoneal mesothelial cell death induced by high-glucose solutions during peritoneal dialysis.

Efecto de la midodrina en la hipotensión sintomática en hemodiálisis

Background: Hypotension occurs in 20% of hemodialysis procedures. Aim: To study the effects of midodrine on hypotension during hemodialysis. Patients and methods: Ten patients on chronic hemodialysis and with a history of hypotension during the procedure, were studied. They received midodrine 10 mg per os or placebo during 5 dialytic procedures each, in a double blind cross over design. Results: Blood pressure levels prior to dialysis were similar during the midodrine or placebo administration periods. During dialysis, systolic blood pressure fell 19.3±28 mmHg with midodrine and 23.4±28 mmHg with placebo. Diastolic blood pressure fell 7.3±11.5 mmHg with midodrine and 11.1±12 mmHg with placebo. The reduction in median arterial pressure was also less pronounced with midodrine. Conclusions: Midodrine lessens the fall in arterial pressure during hemodialysis, in patients with symptomatic hypotension (Rev Med Chile 2002; 130: 1009-13)

Diagnóstico y seguimiento de 12 casos de peritonitis esclerosante asociada a diálisis peritoneal crónica en Chile: Experience in 12 patients on peritoneal dialysis

BACKGROUND Encapsulating peritoneal sclerosis (EPS) is a complication of peritoneal dialysis (PD) with a low prevalence but high mortality. It is characterized by peritoneal inflammation and fibrosis with subsequent development of intestinal encapsulation. It is associated with a long lapse on PD, frequent episodes of peritonitis, high glucose solution use, and high peritoneal transport status. AIM To report the clinical features of patients on PD, who developed EPS. MATERIAL AND METHODS Review of medical records of 12 patients aged 43 ± 10 years (eight women) who developed EPS. RESULTS The mean time spent on PD was 98 months. The main clinical manifestations were abdominal pain in 82% and ultrafiltration failure in 63%. In 92%, there was a history of peritonitis and 75% had high peritoneal transport at the time of diagnosis. The main findings in computed tomography were peritoneal calcification and thickening. There was a biopsy compatible with the diagnosis in 10 cases. Treatment consisted in withdrawal from PD, removal of PD catheter and the use of corticoids and tamoxifen. After withdrawal from PD 50% of patients became asymptomatic. The rest had intermittent abdominal pain and altered bowel movements. Two patients died (17%). CONCLUSIONS EPS is a serious complication of PD, which should be suspected in any patient with compatible clinical symptoms, long time on PD, multiple episodes of peritonitis and high peritoneal transport profile.Background: Encapsulating peritoneal sclerosis (EPS) is a complication of peritoneal dialysis (PD) with a low prevalence but high mortality. It is characterized by peritoneal inflammation and fibrosis with subsequent development of intestinal encapsulation. It is associated with a long lapse on PD, frequent episodes of peritonitis, high glucose solution use, and high peritoneal transport status. Aim: To report the clinical features of patients on PD, who developed EPS. Material and methods: Review of medical records of 12 patients aged 43 ± 10 years (eight women) who developed EPS. Results: The mean time spent on PD was 98 months. The main clinical manifestations were abdominal pain in 82% and ultrafiltration failure in 63 %. In 92 %, there was a history of peritonitis and 75 % had high peritoneal transport at the time of diagnosis. The main findings in computed tomography were peritoneal calcification and thickening. There was a biopsy compatible with the diagnosis in 10 cases. Treatment consisted in withdrawal from PD, removal of PD catheter and the use of corticoids and tamoxifen. After withdrawal from PD 50% of patients became asymptomatic. The rest had intermittent abdominal pain and altered bowel movements. Two patients died (17 %). Conclusions: EPS is a serious complication of PD, which should be suspected in any patient with compatible clinical symptoms, long time on PD, multiple episodes of peritonitis and high peritoneal transport profile.

The Fortress Becomes a Prison: Calcified Constrictive Pericarditis

PRESENTATION The pericardium, normally so useful in defending the heart from outside invaders, can perform more like a cage when its flexibility is compromised. We present the case of a 50-year-old man who was admitted to the nephrology unit when severe chronic hypotension led to poor hemodynamic tolerance during hemodialysis. He had a 24-year history of kidney disease of unknown etiology. At debut, he presented with pericardial effusion that required urgent initiation of hemodialysis. In 1993, he underwent a kidney transplant. Chronic graft dysfunction evolved, and in 2010, he started hemodialysis again. His medical history included chronic liver damage secondary to venous-occlusive disease induced by azathioprine and mesenteric thrombosis managed with oral anticoagulation. In 2011, he underwent subtotal parathyroidectomy for hyperparathyroidism.

Caso clínico: cistitis enfisematosa asociada a hidronefrosis secundaria

We report a 53 year-old woman with type 2 diabetes mellitus and hypertension, presenting with progressive abdominal pain lasting three weeks, associated with lower abdominal swelling and fever. Clinical examination showed a large increase in abdominal volume, contraction of extracellular compartment, and signs of severe sepsis. Computed tomography showed an over-distended bladder with severe wall and luminal pneumatosis and bilateral hydronephrosis. The diagnosis was of emphysematous cystitis associated to hydronephrosis. Urine and blood cultures were positive for multi-susceptible Escherichia coli. Clinical evolution was favorable after 6 weeks of ceftriaxone and urinary catheter use. Emphysematous cystitis is a rare clinical entity, with an associated mortality of 7%. Known predisposing factors are older age, female gender and presence of diabetes. Microbiological agents most frequently involved are Escherichia coli and Klebsiella pneumoniae (80% of cases). Medical treatment is preferred and is based on urinary tract decompression with a bladder catheter, and prolonged broad spectrum antimicrobial therapy.We report a 53 year-old woman with type 2 diabetes mellitus and hypertension, presenting with progressive abdominal pain lasting three weeks, associated with lower abdominal swelling and fever. Clinical examination showed a large increase in abdominal volume, contraction of extracellular compartment, and signs of severe sepsis. Computed tomography showed an over-distended bladder with severe wall and luminal pneumatosis and bilateral hydronephrosis. The diagnosis was of emphysematous cystitis associated to hydronephrosis. Urine and blood cultures were positive for multi-susceptible Escherichia coli. Clinical evolution was favorable after 6 weeks of ceftriaxone and urinary catheter use. Emphysematous cystitis is a rare clinical entity, with an associated mortality of 7%. Known predisposing factors are older age, female gender and presence of diabetes. Microbiological agents most frequently involved are Escherichia coli and Klebsiella pneumoniae (80% of cases). Medical treatment is preferred and is based on urinary tract decompression with a bladder catheter, and prolonged broad spectrum antimicrobial therapy.