Uterine leiomyoma causing urinary obstruction of the transplanted kidney.

Obstruction of the ureter as a cause of acute or chronic kidney injury in the transplanted kidney is unusual beyond the perioperative period. We present a case of ureteric obstruction, infection and septicemia caused by a large uterine leiomyoma in a patient 8 years post transplantation. Initial treatment comprised of intravenous fluid and antibiotics followed by urgent drainage of the collecting system. Subsequent hysterectomy resolved the obstruction with resolution of renal failure. In young female kidney transplant recipients, gynecologic causes, although rare, need to be considered as possible etiologies of urinary obstruction and renal dysfunction.

Delayed renal allograft dysfunction and cystitis associated with human polyomavirus (BK) infection in a renal transplant recipient: a case report and review of literature.

Human polyomavirus type BK (BKV) associated nephritis (BKVAN) has recently emerged as an important cause of renal allograft dysfunction and failure. Early recognition of this entity as a cause of allograft dysfunction is extremely important since misdiagnosis can accelerate graft loss. We report a case of BKVAN that presented with symptoms related to cystitis, and review the risk factors, the diagnostic tools and the approach to treatment of BK virus associated allograft nephropathy.

Recurrent severe anion gap metabolic acidosis secondary to episodic ethylene glycol intoxication.

Acute ethylene glycol toxicity and its attendant metabolic derangement is a well described clinical entity. Recurrent severe anion gap metabolic acidosis consequent to episodic ingestion of ethylene glycol has not been previously reported. We present a patient who developed severe anion gap metabolic acidosis with no osmolar gap and hypokalemia, consequent to episodic ethylene glycol ingestion. Modest artifactual elevation of the serum lactic acid level and rapid response to intravenous bicarbonate infusion may serve as diagnostic clues. Consideration of these aberrant features should be included in the clinical assessment of severe anion gap metabolic acidosis.

Use of Amuchina 50% solution versus povidone-iodine 10% solution for transfer-set change in peritoneal dialysis patients.

The goal of this study was to compare the safety and efficacy of Amuchina 50% solution versus that of povidone-iodine 10% solution for transfer-set change in peritoneal dialysis (PD) patients in a tertiary referral university hospital. The transfer sets were changed using povidone-iodine 10% solution as disinfectant prior to March 1995. Thereafter Amuchina 50% solution was used. Thus data were collected on all the transfer sets changed between January 1993 and August 1997. Amuchina is an electrolytic chloroxidizer. Chlorine is the active ingredient with a pH of 9.5-10.5. Amuchina 50% solution contains chlorine (0.55%). One hundred ninety-nine transfer sets were changed using povidone-iodine 10% solution in 60 PD patients from January 1993 to March 1995. One hundred twenty-eight transfer sets were changed using Amuchina 50% solution in 65 patients from April 1995 to August 1997. The soaking times and nursing times were 2 and 5 minutes, respectively, with Amuchina, and 10 and 20 minutes, respectively, with povidone-iodine 10%. No episode of peritonitis occurred related to transfer-set change in either group. The transfer-set change using Amuchina 50% solution is safe and cost-effective in PD patients.

Serum albumin and depression in end-stage renal disease.

The purpose of our study was to determine whether albumin influenced patients' depression or whether depression influenced patients' albumin. Patients from a tertiary care university medical hospital were assessed for both serum albumin and depression [Beck Depression Inventory (BDI)] at two time points separated by 6 months. Data were collected for 72 patients (43 male, 29 female; mean age 54 years). The sample consisted of 32 hemodialysis and 40 peritoneal dialysis patients. The outcome measures were changes in depression and albumin over time. Regression analysis indicated that all three Time 1 measures of BDI, BDICOG (BDI cognitive), and BDISOM (BDI somatic) significantly predicted decreases in albumin from Time 1 to Time 2 (beta = -0.22, p < 0.002; beta = -0.17, p < 0.015; beta = -0.23, p < 0.002, respectively). However, Time 1 measures of albumin did not predict changes in BDI, BDICOG, or BDISOM (beta = -0.04, p < 0.738; beta = -0.08, p < 0.375; beta = -0.07, p < 0.618, respectively). Thus depression at Time 1 predicted decreases in albumin from Time 1 to Time 2. The reverse effect that albumin influences depression from Time 1 to Time 2 was not found. In conclusion, this study suggests that depression influences the nutritional status indicated by albumin levels. Thus poor nutritional status may mediate the relation between depression and mortality in end-stage renal disease (ESRD).

Decreased L-arginine during peritonitis in ESRD patients on peritoneal dialysis.

Deficient production of nitric oxide may be responsible for the defective defense barrier and persistence of bacterial infection. To gain insight into amino acid-metabolism and L-arginine-nitric oxide system, we studied 34 end-stage renal disease (ESRD) patients on peritoneal dialysis (PD) (20 males, 14 females, with a mean age of 53.5 years and a mean duration on PD of 29.7 months). The concentrations of amino acids, including L-arginine, were measured in peritoneal dialysate and in the serum. The data demonstrated that patients with ESRD on PD have normal serum amino-acid profiles, whereas those with acute peritonitis develop L-arginine deficiency (from 99 +/- 9 to 52 +/- 9 mumol/L). In addition, levels of asparagine, glycine, proline (nonessential) as well as valine, threonine, and lysine (essential) were reduced in patients with peritonitis. The majority of patients with acute bacterial peritonitis have increased nitric oxide production as judged by the level of nitrites in the dialysate (36 +/- 2 vs 57 +/- 6 mumol/L). The recovery from peritonitis was associated with a decline in nitric-oxide generation. There was a smaller subgroup of these patients that showed paradoxically low nitrite levels during acute peritonitis. The nitrite: L-arginine ratio in the peritoneal dialysate was increased in patients with peritonitis, further suggesting the development of substrate deficiency. These findings implicate L-arginine as a conditionally essential amino acid in PD patients with acute peritonitis. Further studies are needed to address the issue of L-arginine supplementation in such patients.

Persistent exit-site/tunnel infection and subcutaneous cuff removal in PD patients.

The purpose of our study was to investigate catheter outcome of persistent exit-site/tunnel infections (ESI/TIs) in peritoneal dialysis (PD) patients. The patients underwent removal of subcutaneous cuff due to persistent ESI/TI from January 1989 to December 1996 in a tertiary referral university hospital. Two hundred and twenty-three patients (138 male, 85 female) underwent 244 double-cuff coiled Swan neck catheter implantations surgically. Twenty-nine patients (11.8%) had persistent ESI/TI for more than 6 months with the same organism. Sixteen patients (52%) underwent subcutaneous cuff excision. Thirteen (48%) patients refused and were managed conservatively. Two hundred and forty-three episodes of ESI/TI were observed over 4970 patient-months with a rate of 0.58 episodes/patient/year. Twenty-nine patients (11.8%) had persistent ESI/TI with S. aureus in 19, Pseudomonas aeruginosa in 9 (31%), and Serratia marcescens in one (3%) patient. Fourteen (88%) persistent ESI/TIs resolved after subcutaneous cuff excision. None of the patients with ESI/TI responded to conservative treatment. ESI/TI-related peritonitis decreased from 11 episodes to 5 episodes after cuff excision. In contrast, episodes of peritonitis increased from one to 9 with conservative management during a follow-up of mean 18 months (4-38 months). Four (31%) catheters were lost in the conservative group, while 3 (19%) were lost after cuff excision. ESI/TI-related peritonitis decreased after subcutaneous cuff excision but increased with conservative management for ESI/TI. ESI/TI resolved in 88% of the patients after cuff excision, while none resolved with conservative treatment.

A comparison of attributions, health beliefs, and negative emotions as predictors of fluid adherence in renal dialysis patients: a prospective analysis.

Excessive fluid intake in hemodialysis patients can lead to serious cardiovascular complications. However, previous studies have not investigated factors that affect fluid adherence over time. The influence of three sets of factors--attributions, health beliefs, and negative emotions--was examined to determine their influence on changes in fluid adherence over time. We assessed patient's fluid-intake changes across two time periods, as well as their absolute level. The results indicated that attributions, while predicting absolute fluid adherence, did not predict changes in fluid adherence. On the other hand, health beliefs predicted changes in fluid adherence but not absolute levels. Negative emotions predicted neither absolute nor changes in fluid adherence. It is suggested that attributions are more responsible for maintenance and control of stable fluid adherence levels, while health beliefs are more responsible for motivational factors related to changes in fluid adherence over time.

Accuracy or bias in nurses' ratings of patient compliance: a comparison of treatment modality.

OBJECTIVE: The study examined the accuracy of nurses' assessments of patient compliance and identified factors influencing these assessments, including possible biases. DESIGN: Nurses' assessments of compliance, lab serum levels of dietary compliance, and interdialytic weight gain (IWG) were collected and compared to each other. End-stage renal disease (ESRD) patients on peritoneal dialysis (PD) and hemodialysis (HD) were compared on these measures and their compliance. SETTING: The study was conducted at the tertiary care university hospital at Stony Brook. PATIENTS: Data were collected for 62 ESRD patients (38 male, 24 female; mean age 54 years). The sample consisted of 26 HD and 36 PD patients. INTERVENTIONS: Nurses rated patients' compliance with fluid restrictions (HD patients only) and overall dietary compliance, as well as individual indicators of compliance including protein, potassium, and phosphorus compliance on a 7-point rating scale. Interdialytic weight gain, dietary (serum BUN and K levels), and medication compliance were recorded from charts for a 3-month period for each patient. MAIN OUTCOME MEASURES: The main outcome measures were the correlations between nurses' ratings of compliance and medical compliance data and the regression coefficients, which indicate the relative importance of each of the factors that nurses use to make their compliance ratings. RESULTS: Nurses' ratings for patients in both treatment modalities were highly correlated with the medical data for measures of fluid (r = 0.66, p < 0.001), potassium (r = 0.36, p < 0.01), and phosphorus (r = 0.36, p < 0.01). A regression analysis indicates that potassium (beta = 0.48, p < 0.001), phosphorus (beta = 0.19, p < 0.05), and protein (beta = 0.31, p < 0.01) all significantly contributed to nurses' assessments of patients' overall compliance. However, nurses' ratings of education levels for patients in both treatment modalities were not associated with phosphorus (r = 0.07, p < 0.61), protein (r = 0.18, p < 0.23), or potassium (r = 0.03, p < 0.85) measures. Finally, regressions revealed that nurses used personal knowledge of the patients when rating noncompliant patients (beta = 0.49, p < 0.05) but not when rating compliant patients (beta = 0.05, p < 0.75). CONCLUSIONS: Nurses rely heavily on medical records to rate patients' compliance and to make accurate assessments. Nurses also use several individual indicators (lab values and IWG) to rate overall dietary compliance, suggesting a thorough assessment. While assessments are not biased by personal factors such as nurses' perceptions of patients' education levels, nurses do rely on personal knowledge when rating noncompliant patients.

Weight reduction and fluid intake in an obese and fluid noncompliant ESRD patient.

This case study describes the application of a behavioral weight reduction program to an obese ESRD patient who was also fluid noncompliant. The major purpose of the study was to determine whether the behavioral weight reduction program could be successfully applied to a hemodialysis patient, and if so, what effect reduced caloric intake would have on fluid intake. Based on animal and human studies showing a strong relation between eating and drinking, it was expected that body weight reduction would be accompanied by reduced fluid intake. On the other hand, an alternative psychological hypothesis suggested that increased fluid intake might be substituted for reduced food intake. The results of the weight reduction program indicated that a successful weight reduction of 42 lbs was maintained over an 18-month follow-up period. However, fluid intake increased during periods when caloric intake was reduced. Overall, the results indicated that behavioral weight reduction programs can be successfully applied to weight reduction in obese hemodialysis patients but that ways to avoid increased fluid intake need to be carefully addressed by such programs.

Plasminogen activator inhibitor-1 and peritoneal transport in peritoneal dialysis patients.

Plasminogen activator inhibitor-1 (PAI-1) is involved in the accumulation of extracellular matrix in various tissues. Since peritoneal interstitium is one of the resistance sites for transport during peritoneal dialysis (PD), the peritoneal PAI-1 level may have a significant effect on peritoneal transport. It was the purpose of this study to examine the associations between plasma or dialysate PAI-1 levels and the variables of peritoneal transport during peritoneal equilibration tests (PET) in 25 stable, adult PD patients. The dialysate PAI-1 levels increased with dwell time. Hematocrit was a positive predictor of plasma PAI-1 concentration and the change of dialysate PAI-1 amount scaled by body surface area (delta DPAI/ BSA). The peritoneal clearance of PAI-1 was higher than expected for its molecular size, suggesting a local production of PAI-1 in peritoneal tissue. The mass transfer coefficient of creatinine scaled by BSA (MTCcr/BSA) was a positive predictor of delta D PAI/BSA, suggesting the diffusion of plasma PAI-1 into the peritoneal cavity also accounted for part of the increased dialysate PAI-1 levels during PET. delta DPAI/BSA was a positive predictor of MTC of urea (ur) MTCwr/BSA and MTCcr/BSA, parameters for diffusive transport. Our findings are consistent with the hypothesis that peritoneal PAI-1 level has a significant effect on peritoneal transport during PD.

Antifungal prophylaxis for secondary fungal peritonitis in peritoneal dialysis patients.

Our objective was to evaluate antifungal prophylaxis for secondary fungal peritonitis in peritoneal dialysis patients. The study was designed to investigate antifungal prophylaxis for fungal peritonitis and to compare the incidence of fungal peritonitis without (January, 1991-July, 1993) and with (August, 1993-December, 1995) antifungal prophylaxis. In a tertiary-referral university hospital, 122 end-stage renal disease (ESRD) patients (77 male, 45 female) during period A (1/91-7/93) were observed for 1832 patient-months with no antifungal prophylaxis. One hundred and twelve ESRD patients (71 male, 41 female) during period B (8/93-12/95) were observed over 1705 patient-months with antifungal prophylaxis with fluconazole. Fluconazole 200 mg was given orally (po) as first dose at the onset of antibiotic therapy, then 100 mg po every other day, and was continued for one week after the antibiotic therapy. Forty-nine patients (28 male, 21 female; mean age 48.8 years) developed 105 episodes of peritonitis during period A. Forty-eight patients (36 male, 12 female; mean age 53.8 years) developed 95 episodes of peritonitis during period B. Fifteen episodes of fungal peritonitis occurred over 1832 patient-months during period A. while four episodes of fungal peritonitis were observed over 1705 patient-months during period B. Twelve episodes of secondary fungal peritonitis occurred during period A, while only two episodes occurred during period B. This incidence of secondary fungal peritonitis was significantly reduced with antifungal prophylaxis (p < 0.02). No side effect of fluconazole was observed. In conclusion, secondary fungal peritonitis was significantly decreased following fluconazole antifungal prophylaxis at our center.

Endogenous peritonitis and related outcome in peritoneal dialysis patients.

Our objective was to study endogenous peritonitis and related catheter outcome in peritoneal dialysis (PD) patients. The study was designed to investigate endogenous peritonitis and related catheter loss in all end-stage renal disease (ESRD) patients who started peritoneal dialysis from January, 1989 to September, 1995. In a tertiary-referral university hospital, 192 ESRD patients (117 male, 75 female) who entered the home program from 1/89 to 9/95 were studied. Sixteen episodes of endogenous peritonitis occurred in 15 PD patients (7 male, 8 female) with a mean age of 63 years (range 33-81 years). Five patients were diabetic. Two hundred and seventeen episodes of peritonitis in 192 patients occurred over 4149 patient-months, resulting in one episode/19.1 patient-months. Sixteen episodes of endogenous peritonitis were encountered in 15 patients, accounting for 7% of all episodes of peritonitis. The mean duration of PD before contracting endogenous peritonitis was 24.2 months (range 7-52 months). Eleven episodes were related to diverticular leak/perforation, three to sigmoidoscopy/colonoscopy/PEG procedures, one to unknown etiology, and one to cholecystitis. During 11 episodes, severe constipation preceded. All the patients were initially treated conservatively with antibiotics. Five episodes (31%) responded to antibiotic therapy alongside antifungal prophylaxis and continued PD. One episode (6%) required cholecystectomy without catheter removal and resumed PD. Six episodes (38%) required catheter removal due to subsequent fungal peritonitis in a mean of 11 days (range 3-24 days): 4 patients transferred to hemodialysis and 2 patients resumed PD. Three patients underwent catheter removal along with colectomy and colostomy: 2 patients transferred to hemodialysis and 1 patient died in ten days. One patient refused surgery and died in 16 days. Endogenous peritonitis resulted in a high incidence of catheter loss and dropout from PD. Peritonitis due to bowel leak without frank bowel perforation can be managed with antibiotic therapy and antifungal prophylaxis. Aggressive management of constipation may decrease endogenous peritonitis.

Multiple use of disposable (tubing) set of HomeChoice automated peritoneal dialysis (APD) system in PD patients.

Our objective was to evaluate the multiple use of the tubing set of the HomeChoice automated peritoneal dialysis (PD) system in PD patients. The study was designed to reuse the tubing set of the HomeChoice automated PD system for two to seven treatments, each of 16-24 hours duration, in end-stage renal disease (ESRD) patients, and to continue to use the same set if the patient was disconnected for any reason. In a tertiary-referral university hospital, 17 ESRD patients on PD, admitted to a university hospital from January, 1995 to September, 1995, were studied. The patients were disconnected and connected in between or during PD treatments. Five-liter bags were used. All the fluid was either set initially or added as clinically indicated. One hundred and thirty-eight PD treatments were performed with the HomeChoice automated PD system, using 30 disposable (tubing) sets. Sixty-three disconnections were made for ambulation, transfer to other units, surgery, physical therapy, radiological investigations, and special procedures in between and during PD treatments. No episode of peritonitis occurred. The multiple use resulted in a 78% reduction in tubing sets and drain-line extension sets used, thereby reducing the disposable supplies and creating a substantial saving in nursing time. The multiple use of tubing sets of the HomeChoice automated PD system was safe and economical in patients undergoing automated PD in a hospital setting.

Plasminogen activator inhibitor-1 and peritoneal transport in diabetic and non-diabetic peritoneal dialysis patients.

Plasminogen activator inhibitor-1 (PAI-1) is an important regulator of plasminogen activators and has been shown to be involved in the accumulation of extracellular matrix (ECM) in various tissues. Since peritoneal interstitium is one of the main resistance sites of peritoneal transport, the level of PAI-1 in the peritoneum may have a significant effect on water and solute transport during peritoneal dialysis (PD) via its effect of peritoneal ECM. Therefore, we studied the associations between plasma or dialysate PAI-1 levels and the peritoneal transport during standard peritoneal equilibration test (PET) in 8 diabetic and 8 non-diabetic stable PD patients who were matched for their demographical data. There were no differences in plasma PAI-1 levels and PET variables between these two groups of patients. In each group, there was an increase in dialysate PAI-1 level with dwell time as a result of the diffusion of plasma PAI-1 into peritoneal cavity and the local production and release of PAI-1 in peritoneal tissue. However, the extent of this increase was less in the former. In non-diabetic patients, the change in dialysate PAI-1 amount was a significant positive predictor for the diffusive transports of urea and transport. These results are consistent with the hypothesis that peritoneal PAI-1 has a significant effect on peritoneal transport during PD. Further studies including more patients are needed to confirm our observations, and studies providing more direct evidence are needed to test this hypothesis.

Burden of self-care in seriously ill patients: impact on adjustment.

Perceived, but not actual, control over the treatment has been consistently related to better adjustment in chronic illness. This study examined the relationship between actual control over treatment and severity of illness and their influence on depression in a chronically ill population of end-stage renal disease (ESRD) patients. The authors hypothesized that as severity of illness increases, the burden of control over treatment would increase depression. Severity of illness and depression were assessed for 98 ESRD patients. Control over treatment was represented by whether dialysis patients were self-administering treatment (high control) or were receiving treatment from the medical staff (low control). Results indicated that for the most severely ill patients, high control over treatment resulted in poorer adjustment. Furthermore, this effect was due in part to how illness interferes with social relationships in seriously ill, self-care patients.

Subcutaneous cuff removal in persistent exit-site/tunnel infections in peritoneal dialysis.

The purpose of this study was to analyze catheter outcome of persistent exit-site/tunnel infections (ESI/TIs) in peritoneal dialysis patients who underwent removal of the subcutaneous cuff due to persistent ESI/TI from January 1989 to June 1994. One hundred and sixty-eight patients (98 male, 70 female) from our tertiary university hospital underwent 177 double-cuff coiled Swan neck catheter implantations surgically. Nineteen patients (11%) had persistent ESI/TIs for more than 6 months. Thirteen persistent ESI/TIs responded to subcutaneous cuff removal. One hundred and fifty-four episodes of ESI/TI in 168 patients were observed over 3189 patient-months (0.58 episodes/patient-year). Nineteen patients (11%) had persistent ESI/TI with Staphylococcus aureus in 12 and Pseudomonas aeurginosa in 7 patients without episode of peritonitis except 2 patients with Staphylococcus aureus. Thirteen persistent ESI/TI resolved after subcutaneous catheter removal without catheter loss, 8 with Staphylococcus aureus and 5 with Pseudomonas. Sixteen catheters were lost due to fungal peritonitis and two secondary to recurrent bacterial peritonitis. None of the catheters were removed as a result of ESI/TI and related peritonitis. Subcutaneous cuff removal in persistent ESI/TI in peritoneal dialysis patients can significantly reduce catheter loss related to ESI/TI.

Peritoneal transport in type I (insulin-dependent) and type II (noninsulin-dependent) diabetic peritoneal dialysis patients.

Alterations in the fibrinolytic system have been demonstrated in noninsulin-dependent diabetic patients (NIDDM) but not in insulin-dependent diabetic patients (IDDM). Since the activity of the fibrinolytic system can affect the turnover of extracellular matrix and therefore theoretically can affect the peritoneal transport, we tried to determine if there was a difference in the performance of the peritoneal equilibration test (PET) between IDDM and NIDDM patients receiving peritoneal dialysis (PD). The PET data from 11 IDDM patients (2 female, 9 male) and 13 NIDDM patients (3 female, 10 male) were reviewed. These two groups of patients were matched in gender, duration of end-stage renal disease, PD, and hypertension, blood pressure, degree of uremia, weekly KT/V, and body surface area. The IDDM patients (41.4 +/- 13.9 years) were younger than the NIDDM patients (58.8 +/- 7.1 years, p = 0.0026). There were no differences in hematocrit and serum chemistry profile including glucose and albumin between the two groups. Our data showed that there was no difference in PET performance between IDDM and NIDDM patients.

Increased peritoneal solute transport in diabetic peritoneal dialysis patients.

Microangiopathy has been observed in the peritoneum of diabetic patients, and an increase in vascular permeability to small and large molecules has been described in the skeletal muscle of diabetic patients. Therefore, we examined the peritoneal equilibration test (PET) data from 19 diabetic and 19 nondiabetic stable peritoneal dialysis (PD) patients. These two groups of patients were matched in terms of age, gender, duration of PD and hypertension, incidence of peritonitis, levels of blood pressure, degree of uremia, levels of serum lipids, hematocrit, weekly KT/V, and body surface area. Compared to the nondiabetics, the diabetics had higher dialysate-to-serum ratios or mass transfer coefficients of urea or creatinine. These differences were not related to their differences in serum sodium or glucose. Regression analysis showed that the duration of hypertension was a negative determinant of peritoneal transport of urea and creatinine in diabetic patients. Our results suggest that the diabetic patients had a higher peritoneal diffusive transport of small solutes, which was offset by their duration of hypertension.