Protein nutrition index as a function of patient survival rate in peritoneal dialysis.

BACKGROUND/AIMS: Protein-energy wasting (PEW) is a well-known risk factor of long-term survival in peritoneal dialysis (PD) patients. Serum albumin is a measure of visceral protein, lean body mass is a measure of somatic protein stores and normalized protein nitrogen appearance is a measure of daily protein intake. A protein nutrition index (PNI) that combined these 3 factors was designed and tested as a function of survival in PD patients. METHODS: We enrolled 552 PD patients for this study. Demographic, biochemical, nutritional markers, comorbidity and dialysis-related data were obtained. The PNI was calculated. All patients were followed up to investigate the risks for mortality. RESULTS: Patients with probable PEW/low-average nutrition were older and had lower serum creatinine (Cr) and blood urea nitrogen, lower adequacy data and higher D4/P4 Cr compared with patients with high-average/good nutrition. 108 patients (19.6%) died during the observational period. By multivariate analysis, we found only age, comorbidity index and PNI (relative risk = 0.84, confidence interval: 0.76-0.93, p = 0.001) to be independent predictors of mortality. CONCLUSION: The PNI at the start of PD is associated with all-cause mortality, and each increase by a score of 1 in PNI leads to a 16% decrease in the risk of mortality. Predialysis evaluation of this scoring system is recommended for further research in order to improve outcomes in PD patients.

Peritoneal dialysis-related peritonitis caused by Gemella morbillorum in a patient with systemic lupus erythematosus receiving steroid therapy.

Gemella morbillorum, a Gram-positive coccus, is a natural inhabitant of the human oropharyngeal, upper respiratory and gastrointestinal tracts. Human infections caused by this organism are rare. We describe a case of peritoneal dialysis-related peritonitis due to G. morbillorum in a patient with systemic lupus erythematosus receiving steroid therapy. The patient responded well to antibiotics, without removal of the peritoneal catheter.

Type B aortic dissection with early presentation mimicking acute pyelonephritis.

Aortic dissection is a life-threatening illness requiring early diagnosis and treatment. Uncommon early presentations mimicking various illnesses can delay diagnosis. This case study describes a 44-year-old woman with type B aortic dissection initially presenting as acute pyelonephritis (APN). Early clinical manifestations were sudden onset of left flank pain, fever, hematuria and pyuria, and following admission, severe abdominal pain, nausea, vomiting, reduced urine output and renal function deterioration. Abdominal computed tomography showed type B aortic dissection complicated with a small bowel infarct, ischemic ascending colon and left renal infarct. Emergency surgical interventions of small bowel resection, ileoduodenostomy and cholecystectomy were performed; a second laparotomy was subsequently performed for anastomosis leakage. The patient died due to septic shock with multiorgan failure. Aortic dissection initially mimicking APN is rare. Accurate early diagnosis of aortic dissection with indeterminate presentation is crucial. Early surgical intervention for visceral organ ischemia is important to preventing morbidity and mortality.

Complications mimicking lupus flare-up in a uremic patient undergoing pegylated liposomal doxorubicin therapy for cervical cancer.

Patients with systemic lupus erythematosus (SLE) have an increased risk for malignancy and end-stage renal disease itself might further augment the risk. Treating uremic patients with cervical cancer by cisplatin-based chemotherapy combined with radiation is hampered by the reduced renal excretion of cisplatin. Doxorubicin, a potential radiosensitizer with an established effect on carcinomas that arise in the ovary, uterine cervix and endometrium, might be applied in these cases. We describe a 36-year-old woman, who had a 9-year history of SLE and was maintained on dialysis, and who developed severe drug reaction manifesting as fever, skin rash and exfoliative dermatitis with positive lupus band test after infusion of pegylated liposomal doxorubicin therapy for advanced cervical cancer. These skin manifestations improved after i.v. methylprednisolone pulse therapy.

Upper urinary tract tumor in a duplicated collecting system: report of three cases and review of the literature.

Despite the common anomaly of a duplicated collecting system in the urinary tract, urothelial cancer in a duplicated collecting system is a rare occurrence. Herein, we present 2 cases of renal pelvis tumor and 1 case of a ureter tumor which coexisted with a duplicated collecting system. One of the renal pelvis tumors developed bilateral transitional cell carcinoma within the bilateral duplicated pelvis. This has not been reported previously. The tumor of the ureter in the latter case was located at the junction site of the bifurcation. This finding is consistent with the postulation that urine reflux chronically irritates the distal segment of a duplicated ureter, rendering this segment susceptible to malignant change. Recurrence of the tumor is frequently observed, which necessitates an early diagnosis and radical treatment.

Improvement in clinical outcome by early nephrology referral in type II diabetics on maintenance peritoneal dialysis.

OBJECTIVES: To evaluate the influence of early nephrology referral on clinical outcome in type II diabetes mellitus patients on maintenance peritoneal dialysis (PD). DESIGN: This is a retrospective study in a single University Hospital in Taiwan. PATIENTS: This study analyzed the type II diabetic patients entering our PD program from February 1988 to June 2000. Patients that were presented to a nephrologist more than 6 months before starting dialysis were defined as early referrals (ER). Patients were considered late referrals (LR) if they were transferred to the nephrology department within 6 months before initial dialysis. MAIN OUTCOME MEASURES: Patient survival and technique survival curves were derived from Kaplan-Meier analysis and were compared using the Cox-Mantel log rank test. Covariates were analyzed with Cox proportional hazards model. RESULTS: 52 type II diabetic patients were enrolled in this study: 16 in the ER group and 36 in the LR group. Patient survival was better in the ER group than in the LR group [relative risks [exp(coef)] 0.42; 95% confidence interval 0.152-0.666; p < 0.05]. The improved survival in the ER group was independent of age at dialysis, good glycemic control, and residual renal function, as indicated in the multivariate analysis with stepwise regression by Cox proportional hazards model. The ER group was also associated with better technique survival. CONCLUSIONS: These results suggest that early nephrology referral before initiating dialysis is associated with improved long-term clinical outcome in type II diabetics on maintenance PD.

Improved iron utilization and reduced erythropoietin resistance by on-line hemodiafiltration.

BACKGROUND: Recent investigation has shown that on-line hemodiafiltration (HDF) can reduce the amount of recombinant human erythropoietin (rhEPO) deemed necessary to reach the target hematocrit. The aim of this study was to analyze the potential effect of on-line HDF on rhEPO resistance in relation to iron utilization and anemia-related parameters, when compared to conventional hemodialysis (HD). METHODS: Ninety-two chronic uremic patients were treated with conventional HD and then shifted to on-line HDF. Measurements of various erythropoiesis-related parameters were collected during HD and on-line HDF periods for statistical analysis for erythropoietin resistance. RESULTS: Patients treated with on-line HDF switching from conventional HD significantly contributed to the reduction of EPO dose to reach a higher mean hematocrit level (31.8 +/- 4.4% vs. 29.5 +/- 3.9%, p < 0.001) and a reduction of the serum ferritin level (322.5 +/- 268.4 vs. 544.9 +/- 642.4, p < 0.001). The median EPO/Hct ratio was greater in the HD period (504.6 +/- 310.1) than in the on-line HDF period (307.6 +/- 334.4) (p < 0.001). These results indicated a reduced EPO resistance and improved iron utilization by on-line HDF. By multiple regression analysis, the significant predictors of EPO resistance are ferritin, transferrin, albumin, and TACurea (Time average concentration of urea) in HD treatment. In on-line HDF modality, in addition to ferritin and albumin, the duration of on-line HDF is a negative predictor in EPO resistance. CONCLUSION: When on-line HDF is recommended to chronic dialysis patients, long-term use of this technique provides an efficient means of achieving the goal of an elevated hemoglobulin by reducing EPO resistance, improved iron utilization and may further improve the quality of life.