Oral pulsed calcitriol protocol reduces the prevalence of hyperparathyroidism in a PD unit.

A quality assessment (QA) activity revealed that the percentage of parathyroid hormone (PTH) levels above 300 micrograms/dL was higher in the peritoneal dialysis (PD) unit than in the hemodialysis (HD) unit (44% vs 27%). To reduce the proportion of patients with a target PTH above 200 micrograms/dL, a protocol that emphasized control of the serum phosphate level, standard pulsed doses of calcitriol, and increased patient education was created for the management of renal osteodystrophy. Serum calcium, phosphate, and PTH levels were obtained according to the protocol from July 1994 through June 1996. The percentage of patients achieving a PTH level below 200 micrograms/dL increased from 40% in June 1994 to 57% in June 1996. Significant differences were found in PTH levels at baseline and at test times 1, 2, and 3. Hypercalcemia (Ca > 12) occurred in 4% of the 532 Ca levels drawn during the study period and were due to breaches of protocol. In conclusion, we have confirmed previous work indicating that pulsed calcitriol can control elevated PTH levels in PD patients. Furthermore, we have developed a protocol that can be used as a QA tool to reduce the prevalence of hyperparathyroidism in the outpatient PD setting without inducing excess hypercalcemia.

Estudos baseados nas técnicas de angiografia / Study based in angiography techniques

Este trabalho baseia-se em levantamentos radiométricos feitos nos modos de fluoroscopia e grafia, considerando medidas de feixe primário e secundário, com o objetivo da avaliação das taxas de exposição a que estão submetidos o paciente, o médico, o anestesista e demais membros da equipe executora de exames de radiologia vascular periférica.

Variability in calculations of dialysis adequacy in patients using nightly intermittent peritoneal dialysis compared to CAPD.

Increasing numbers of patients receive peritoneal dialysis using noncontinuous methods such as nightly intermittent peritoneal dialysis (NIPD) rather than continuous ambulatory peritoneal dialysis (CAPD). We hypothesized that blood solute levels before and after NIPD would be large enough to produce significant variability in formulas based on the continuous peritoneal dialysis (PD) model. We found no diurnal differences in serum creatinine in NIPD or CAPD. However, our data demonstrate a 7.9% difference in serum urea measurements from evening to morning in patients treated by NIPD. This mathematical difference contributes to a 6.3% difference in the calculated value of KT/V and a 9.4% difference in the calculation of total urea clearance (liters per week) in these patients. By contrast, no difference in serum values or in calculated values of adequacy could be shown in patients on CAPD. These observations support the premise that CAPD represents a steady-state condition. NIPD patients demonstrate variability in serum levels of urea which may result in inaccurate calculations of dialysis adequacy. When blood samples are obtained in the morning soon after completing a cycle of NIPD, dialysis adequacy as measured by KT/V or total urea clearance (but not by total creatinine clearance) may be systematically overestimated.

Cost-effective automated peritoneal dialysis for patients with average to low transport.

Patients with average to low transport kinetics are generally best dialyzed by standard continuous ambulatory peritoneal dialysis (CAPD) regimens that optimize clearance through longer dwell times. However, patients often request or require automated peritoneal dialysis (APD, also called cycler dialysis) in response to lifestyle issues. Our experience shows that these patients can be economically dialyzed in an 8 to 10 L mixed APD/CAPD regimen reversing the timing of traditional CAPD exchanges. The cost of a 9 L/day mixed regimen is comparable to that of 8 L/day CAPD.

Lack of correlation between nasal cultures positive for Staphylococcus aureus and the development of S. aureus exit-site infections: results unaffected by routine mupirocin treatment of nasal S. aureus carriage.

Whether nasal carriage of Staphylococcus aureus is associated with an increased risk of S. aureus exit-site infection remains controversial. We performed nasal cultures prior to peritoneal dialysis catheter placement in all of our patients beginning in September 1990. We also performed nasal cultures on a cohort of patients already on peritoneal dialysis. Patients with positive cultures received a prescription for a ten-day course of intranasal mupirocin. Exit-site and nasal cultures were performed on every subsequent office visit until the end of the study in April 1993. The initial visit and three widely-spaced subsequent visits were chosen for data analysis. There were 68 patients entered into the study. Data from a total of 272 visits were analyzed. The patients ranged in age from 18-80 years. There were 27 diabetics. We found no correlation between initial positive nasal cultures and the subsequent development of a S. aureus exit-site infection. All identified nasal carriers were treated with mupirocin. However, the subsequent development of a S. aureus exit-site infection could not be correlated to a prior S. aureus carrier state or lack thereof.

A retrospective view of factors that affect catheter healing: four years of experience.

To determine factors that lead to successful healing, the results of catheter placement were collected by retrospective chart review in 103 peritoneal dialysis patients between January 1988 and March 1992. There were a total of 112 catheter insertions. A healing time of less than 2 weeks was defined as an optimal outcome. Data were analyzed using contingency tables. Strong predictors of early and effective healing were the following: exit site size less than 0.7 cm, the use of a tunneler to create the exit site, the use of Swan neck catheters, immobilization using Viasorb dressings, and postoperative prophylaxis with intravenous vancomycin. Dialysate leak and the development of hematomas significantly delayed healing. Leaking was associated with early use of the catheter for peritoneal dialysis. Hematoma formation was associated with the use of a tunneler. Uremic or nutritional status, diabetes, immunosuppressive agents, or HIV-positive did not affect catheter healing. Careful attention to intraoperative and postoperative factors optimizes healing independent of complications of primary disease processes in peritoneal dialysis patients.