Peritonitis associated with intra-abdominal pathology in continuous ambulatory peritoneal dialysis patients.

Features helpful in diagnosis and associated with death were evaluated in 26 episodes of peritonitis associated with intra-abdominal pathology (IAP) in continuous ambulatory peritoneal dialysis (CAPD) patients. Culture of multiple enteric pathogens, or of a single unusual enteric pathogen, from the dialysate was useful for diagnosis in 22/26 instances. Other diagnostic features (fecal material in dialysate, diarrhea containing dialysate, increasing free air in the abdominal cavity) were infrequently found. A comparison of patients who died (n = 11, 42%) and those who survived revealed that death was associated with bowel gangrene (5/6 died), recovery of bacteroides from the dialysate, more frequent and severe comorbid conditions (bacteremia, pneumonia, intra-abdominal and intracerebral bleeding, septic shock, hepatic failure), the development of severe malnutrition and thrombocytopenia during infection, and multiple surgical procedures until the diagnosis was established. Peritonitis associated with intra-abdominal pathology in CAPD patients is a severe infection with considerable diagnostic difficulty and high mortality. Early exploratory laparotomy upon suspicion of the nature of the peritonitis, usually raised by the recovery of enteric pathogens from the dialysate, may improve mortality.

Hand gangrene in diabetic patients on chronic dialysis.

To determine whether any potentially reversible variables are related to the development of hand gangrene in diabetic patients on dialysis, the authors compared 15 patients with hand gangrene (group A) to three control groups of diabetics on dialysis: 20 patients with foot gangrene (group B); 31 patients without gangrene of the extremities (group C); and 20 patients without hand arterial calcifications (group D). All patients in groups A-C had medial arterial calcifications of the hands. Group A patients started dialysis at an earlier age (p less than 0.05), were treated for end-stage renal disease (ESRD) for a longer time period (p less than 0.05), and had a lower mean serum albumin concentration during the dialysis period (p less than 0.05) than the patients in the control groups. Hand gangrene also appeared to be associated with the presence of a functioning arterio-venous fistula in the extremity with the gangrene, with loss of function of renal transplant, and with hyperaluminemia. Other variables, including serum parathormone, were not different for the four groups. Logistic regression showed that the following were risk factors for hand gangrene: hypoalbuminemia, long duration of ESRD treatment, hyperphosphatemia, high insulin dose, hypercholesterolemia, and hypoglycemia. In diabetics on dialysis, gangrene develops in hands with medial arterial calcifications, but does not correlate with measures of calcium or phosphorous metabolism. Predictors of hand gangrene include certain potentially reversible clinical and biochemical variables.

Early and late peritoneal dialysate leaks in patients on CAPD.

Dialysate leaks, which occurred in 386 CAPD patients over 11 years, were analyzed retrospectively. 18 patients developed 21 early leaks (within 30 days of catheter insertion) and 18 patients developed 28 late leaks (beyond 30 days of catheter insertion). 8 patients had multiple (2-6) leaks. Both early and late leaks, particularly if they were multiple, were associated with conditions that affect adversely tissue healing and tensile strength. Median surgical insertion was apparently associated with a higher incidence of early leaks. Early leaks were manifested externally, usually through the exit site, and did not require imaging. Late leaks were manifested usually by poor dialysate outflow, localized edema and subcutaneous fluid collections. One third of the late leaks required radiological imaging. Hernias caused 42% of the late leaks. Early leaks were managed by temporary discontinuation of CAPD alone (57%) or surgery. Most late leaks (67%) required surgery. Conservative means (change to IPD, observation) were applied for the management of a few late leaks. Both early and late leaks resulted frequently in replacement of peritoneal catheters, but only late leaks resulted in permanent discontinuation of peritoneal dialysis. Paramedian surgical insertion, waiting period of 10-14 days between catheter insertion and initiation of CAPD, and low starting dialysate volumes have resulted in apparent reduction of the incidence of the early, but not of the late leaks. Dialysate leaks have serious consequences on the performance of CAPD. Early leaks differ from late leaks in some clinical manifestations. Preventive measures have decreased the incidence of early, but not of the late leaks.

Kidney stones. Medical management and newer options for stone 'removal'.

Patients with recurrent kidney stone disease or stone formers at increased risk of recurrence deserve a thorough metabolic workup. This should be based on a careful history and include urinalysis, serum chemistry studies, and analysis of 24-hour urine collections. Measures to prevent recurrent stone formation are aimed at correcting the metabolic imbalances detected in the workup. A variety of drugs are available that target one or more of the metabolic abnormalities that may be involved. For "surgically active" renal and ureteral stone disease, newer techniques make surgery unnecessary in most cases. Extracorporeal shock wave lithotripsy is becoming the preferred technique for disintegration of upper urinary tract stones. Percutaneous ultrasonic lithotripsy and electrohydraulic disintegration also are widely used. For lower urinary tract stones, the ureteroscope permits either extraction under visualization or ultrasonic disintegration.