Rowland J. Elwell

Combined Furosemide and Human Albumin Treatment for Diuretic-Resistant Edema

OBJECTIVE: To evaluate the clinical usefulness of combined furosemide and human albumin for the treatment of diuretic-resistant edema in patients with nephrotic syndrome and cirrhosis. DATA SOURCES: Clinical literature was accessed through MEDLINE (1966–May 2002). Key search terms included furosemide, albumin, human albumin solution, nephrotic syndrome, and cirrhosis. DATA SYNTHESIS: Hypoalbuminemia, edema, and ascites are often manifestations of nephrotic syndrome and cirrhosis of the liver. Many patients with these conditions are resistant to the effects of diuretics. The combination of furosemide and human albumin solution is occasionally used in these patients. An evaluation of published studies focusing on combined furosemide and albumin in the management of nephrotic syndrome and cirrhosis was conducted. CONCLUSIONS: Published studies report conflicting results regarding the efficacy of combined furosemide and albumin. Although it is difficult to generate firm conclusions, it appears the combination may provide clinical benefits for select patients. Given these findings, we believe that the addition of albumin to enhance diuretic efficacy should be reserved for patients with recalcitrant edema or ascites in whom diuretic doses have been maximized and those with severe hypoalbuminemia.

Factors Associated with Long-Term Antibody Production Induced by Hepatitis B Vaccine in Patients Undergoing Hemodialysis: A Retrospective Cohort Study

Study Objective. To assess the influence of various clinical factors on antibody production induced by hepatitis B vaccine in patients receiving hemodialysis up to 24 months after vaccination.

Stability of Vancomycin in Icodextrin Peritoneal Dialysis Solution

Background: Icodextrin is a glucose polymer used as an alternative osmotic agent in peritoneal dialysis (PD) solutions. There are few data regarding the long-term stability of vancomycin in icodextrin PD solution. Objective: To determine the chemical stability of vancomycin in icodextrin PD solution in polyvinyl chloride containers over a 7 day period at 4, 24, and 37 °C. Methods: Study samples were prepared by adding 2000 mg vancomycin HCl to commercially available 2.0 L bags of icodextrin 7.5% PD solution. Nine bags were prepared and stored in the following conditions: 3 under refrigeration (5 °C), 3 at room temperature (24 °C), and 3 at body temperature (37 °C). Samples were withdrawn from each bag immediately after preparation and at predetermined intervals over the subsequent 7 days. Solutions were visually inspected for precipitation, cloudiness, or discoloration at each sampling interval. Total concentration of vancomycin in dialysate fluid was determined by high performance liquid chromatography. Results: Under refrigeration, a mean ± SD of 99.7% ± 0.5% of the initial vancomycin concentration remained at 168 hours (7 days). At room temperature, 97.5% ± 3.4% remained at 168 hours. At body temperature, 94.3% ± 3.9% remained at 24 hours. Stability was not assessed beyond these time points. Conclusions: Premixed vancomycin-icodextrin PD solutions, whether stored refrigerated or at room temperature, were found to be stable for up to 7 days. However, we recommend that these solutions be kept refrigerated whenever possible. Solutions stored at body temperature were stable for up to 24 hours, permitting the practice of prewarming solutions prior to administration.

Intraperitoneal Cefazolin and Ceftazidime Effects on Human Peritoneal Mesothelial Cell Release of Cancer Antigen–125:

BACKGROUND Intraperitoneal (IP) cefazolin and ceftazidime are recommended as empiric treatment for peritoneal dialysis (PD)–associated peritonitis. Human peritoneal mesothelial cells (HPMCs) may be affected by high IP cefazolin and ceftazidime concentrations. Peritoneal dialysate cancer antigen–125 (CA-125) appearance rate can be used to measure HPMC damage. OBJECTIVE To determine whether IP cefazolin and ceftazidime increase peritoneal CA-125 appearance rate. METHODS The study consisted of 2 phases. In phase I, no antibiotic was administered, and in phase II, patients received IP cefazolin and ceftazidime (15 mg/kg rounded to nearest 100 mg). Phase II occurred immediately after phase I. Each phase used a 4-hour dwell time with 2 L of dextrose 2.5% dialysate. Dialysate samples were collected at 0, 0.5, 1, 2, and 4 hours during each phase. Samples were assayed for CA-125, and CA-125 appearance rate was calculated. RESULTS Thirteen patients were recruited (7 men; aged 44.0 ± 16.0 y). The mean ± SD (range) CA-125 dialysate concentration after phases I and II were 6.6 ± 3.7 U/mL (2.3–15.0) and 6.4 ± 3.8 U/mL (1.6–13.8), respectively (p = 0.46). The CA-125 appearance rate after phases I and II were 51.9 ± 31.3 U/min/1.73 m2 (13.8–113.0) and 50.5 ± 32.9 U/min/1.73 m2 (11.0–104.0), respectively (p = 0.57). The slopes of the regression lines of CA-125 appearance rate were not significantly different between phases I and II. CONCLUSIONS These findings demonstrate that concurrently administered IP cefazolin and ceftazidime have no effect on HPMC release of CA-125 in non-infected PD patients.