Predictors of patient survival in continuous ambulatory peritoneal dialysis 10-year experience in 2 major centers in Tehran

Many factors have been proposed to be associated with higher mortality in patients on continuous ambulatory peritoneal dialysis [CAPD]. However, the relative importance of these factors may differ among patients with different characteristics. We evaluated survival of patients on CAPD and its influencing factors in Iran. We enrolled 282 patients on CAPD between 1996 and 2006 at 2 major CAPD centers in Tehran. Patient survival was investigated during this period. Demographic characteristics, laboratory data, dialysis adequacy parameters, residual renal function, peritoneal transport characteristics, and nutritional status were assessed as potential predictors of the outcome. The mean duration of follow-up was 18.4 +/- 14.5 months. Sixty patients [21%] died during the studied period. In univariate analysis, age, body mass index, history and duration of hemodialysis before CAPD, diabetes mellitus, blood pressure, patient selection criteria, edema, peritonitis, renal residual function, urine volume, dialysis adequacy, and serum levels of cholesterol, triglyceride, intact parathyroid hormone, calcium, and albumin were predictors of patient survival. Multivariate analysis demonstrated that old age, diabetes mellitus, prior hemodialysis longer than 7 months, low serum albumin, calcium, trigelyceride, and parathyroid hormone levels independently predicted mortality, while the use of angiotensin-converting enzyme inhibitors was associated with a better survival. This study showed that older patients on CAPD and diabetics are at a higher risk of mortality. On the other hand, nutritional and metabolic factors are other predictors of mortality. Especial concern should be applied to good nutrition and treatment of comorbidities in these patients

PDpoietin in comparison with eprex in treatment of anemic patients on hemodialysis

PDpoietin is a recombinant erythropoietin alfa that has been introduced by a manufacturer in Iran. We assessed the effectiveness and complications of PDpoietin in comparison with Eprex in anemic patients on hemodialysis. This clinical trial was performed in a multicenter setting. Patients with a hemoglobin level less than 12 g/dL were assigned into 2 groups in order to receive either Eprex [Janssen Cilag] or PDpoietin [Pooyesh Darou] for 3 months. Forty-one and 34 patients completed the study in the PDpoietin and Eprex groups, respectively. The mean hemoglobin levels at baseline were not significantly different between the two groups of patients with PDpoietin and Eprex. In both groups, hemoglobin levels increased significantly, but there were no significant differences between the two groups at months 1, 2, and 3. At the end of the study, the mean hemoglobin levels reached 11.6 +/- 1.7 g/dL and 11.8 +/- 1.9 g/dL, respectively [P = .002; P = .01]. The mean hemoglobin per cumulative of drug dose index [hemoglobin/[erythropoietin dose/1000 x injections per month]] was not significantly different between the two groups at different treatment stages, and it did not change significantly in each group during the course of the study. No serious complications were reported. Eprex and PDpoietin could equally increase the hemoglobin levels with no significant complication. Therefore, PDpoietin can be used for treatment of anemia in patients on dialysis, and the patients will have the advantages of its availability and low price

Acute cellular rejection

The incidence of acute rejection of the kidney allograft in the world has been around 15% during the period between 2001 and 2003. It is clinically defined as an elevation in the level of serum creatinine by more than 0.3 mg/dL and is diagnosed by kidney biopsy. On pathologic examination, the interstitium of the allograft is diffusely edematous and infiltrated by CD4 and CD8 lymphocytes. Tubulitis occurs when the lymphocytes and monocytes extend into the walls and lumina of the tubules. Presence of leukocytes determines infection or antibody-mediated rejection. Typically C4d staining is negative. Other causes of acute allograft dysfunction included prerenal factors, interstitial nephritis, infection, acute tubular necrosis, toxicity by drugs, and obstruction in the urinary tract. The primary diagnostic assessments include history, especially adherence to immunosuppressive therapy, physical examination, blood and urine laboratory tests, measurement of the serum levels of the drugs, and ultrasonography. Diagnosis of acute cellular rejection depends on biopsy, CD20 staining for refractory cases, negative C4d staining, presence of markers of activating lymphocyte, and proteomic study. Treatment of acute cellular rejection in kidney transplant recipients include pulse steroid for the first rejection episode. It can be repeated for recurrent or resistant rejection. Thymoglobulin and OKT3 are used as the second line of treatment if graft function is deteriorating. Changing the protocol from cyclosporine to tacrolimus or adding mycophenolate mofetil or sirolimus might be effective. Prognosis depends on number of rejection episodes, the use of potent drugs, time of rejection from transplantation, and response to treatment

Pharmacokinetic behavior of amikacin in 31 Iranian critically ill septic patients

The pharmacokinetic behavior of amikacin and predictive performance of Sawchuk-Zaske dosing method, have been prospectively evaluated in 31 [16 male, 15 female] critically ill septic patients of mean [ +/- SD] age of 58 +/- 23 years, mean ideal body weight of 59.6 +/- 6.4 kg, mean creatinine clearance of 52 +/- 21.5 ml/min, mean serum albumin of 3.1 +/- 0.5 mg/dl and median APACHE [acute physiology and chronic health evaluation] II score of 26 [with a range of 18 to 33]. In this cross-sectional study, critically ill patients who met the Bone criteria for spesis but had stable creatinine clearance [serum creatinine change <0.5 mg/dl of the baseline] received the ordered dose of amikacin in one hour infusions. Blood sample were collected 30 minute after the third dose, half an hour before the fourth dose which was 1.5 times of the predicted half life of amikacin after the third dose. Cirrhotic patients and patients with renal failure requiring any mode of dialysis were excluded. Vital signs were recorded at each time of blood sampling; serum Mg+, serum albumin and APACHE score were recorded at the time of the first blood sampling. Mean [ +/- SD] of the pharmacokinetic key parameters of amikacin in this population was as follow: Vd=0.390.045 l/kg; Ke=0.141 +/- 0.057 /h; half-life=5.7 +/- 2.06 h; Clearance=54.2 +/- 25.2 ml/min. There was a good correlation between Vd and serum albumin and also APACHE score II [r2=0.83, P=0.033;r2=0.82, P<0.001 respectively]. Mean measured peak and trough amikacin concentrations were 20.9 and 3.2 micro g/ml respectively which were significanthy different [P<0.05 paired t test] from levels, predicted by Sawchuk-Zaske method [33.5 and 4.6 micro g/ml respectively]. Ke, t0.5 and cledrane did not show any statistically significant changes [P>0.05 repeated measure test] amongst three times of blood sampling, but Vd was significanly different [P<0.05]. The overall predictive performance of Sawchuk-Zaske method was poor; in spite of good correlation between predicted and measured parameters when using pooled data