[show abstract][hide abstract] ABSTRACT: Oral intake of ascorbic acid is essential for optimum health in human beings. Continuous ambulatory peritoneal dialysis (CAPD) patients have an increased need for ascorbic acid, because of increased loss through dialysate, reduced intake owing to nausea and loss of appetite, and increased oxidative stress. However, optimum intake is still controversial. We studied 50 clinically stable patients to determine the relationship between oral ascorbic acid intake and serum ascorbic acid (SAA) level. Total oral intake ranged from 28 mg daily to 412 mg daily. Only one patient had an oral intake of ascorbic acid below 60 mg per day. The SAA levels ranged from 1 mg/L to 36.17 mg/L. Although a strong correlation existed between intake and SAA (p < 0.001, R2 = 0.47), the variation in SAA at any given intake level was wide. Of the studied patients, 62% had an SAA < 8.7 mg/L, 40% had an SAA < 5.1 mg/L (below the level in a healthy population), and 12% had a level below 2 mg/L (scorbutic). None of the patients demonstrated clinical manifestations of scurvy. Our results show that, in CAPD patients, ascorbic acid deficiency can be reliably detected only with SAA measurements, and oral intake may influence SAA level. To maintain ascorbic acid in the normal range for healthy adults, daily oral intake needs to be increased above the U.S. recommended dietary allowance to 80-140 mg.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 01/2001; 17:215-8.
[show abstract][hide abstract] ABSTRACT: Protein calorie malnutrition (PCM) is a major predictor of morbidity and mortality in continuous ambulatory peritoneal dialysis (CAPD) patients. Oxidative stress has been implicated as a contributory cause. The relative lack of ascorbic acid, a plasma antioxidant, has been reported in CAPD patients. We therefore examined the correlation between serum ascorbic acid (SAA) and parameters of PCM in a cross-sectional study of 50 clinically stable adult CAPD patients. The mean age of the study group was 61 +/- 11 years; 48% of the patients were male; and 64% had diabetes. The parameters assessed were SAA, serum albumin (S Alb), body mass index (BMI), subjective global assessment (SGA), and lean body mass (LBM). The results (mean +/- standard deviation) were: SAA, 9.44 +/- 8.79 mg/L; S Alb, 31.6 +/- 4.9 g/L; BMI, 24.4 +/- 3.4; LBM, 0.66 +/- 0.14 kg/kg body weight; SGA, 9 of 50 were considered mildly-to-moderately malnourished (the rest were well-nourished). A significant correlation (p < 0.001) was found between SAA and S Alb only with SAA < or = 9 mg/L. No correlation was seen between SAA (at any level) and BMI or LBM. The SAA was not significantly different between the groups as graded by SGA. The data suggest that the mechanisms for low serum albumin in these patients may be related to the role of ascorbic acid as a plasma antioxidant.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 01/2001; 17:219-22.
[show abstract][hide abstract] ABSTRACT: Malnutrition is an important determinant of outcome in patients on dialysis. Its cause is multifactorial and its detection is important when patients embark on dialysis. In this study, we used various indices to assess the prevalence of malnutrition as reflected in protein intake, anthropometric effect, and serum protein level. To avoid the effect that dialysis has on malnutrition, we studied 37 patients who had just started continuous ambulatory peritoneal dialysis (CAPD). Of these new patients, 42% had a residual urea clearance below 1.0 mL/min. In 51% of the patients, serum albumin level was below 33 g/L; in 14%, body mass index was below 19; and in 39%, dietary protein intake was below 0.8 g per kilogram of body weight per day. A total of 76% of our patients had at least one of these three indices. In 8% of the patients, lean body mass was below 60%. We conclude that protein malnutrition is a significant problem in our patients starting CAPD. Dialysis-dependent factors were not implicated, as the patients were studied at the start of dialysis. Low intake of protein was a major problem and may have contributed significantly to malnutrition. The low residual urea clearance implied that dialysis was started relatively late and may have contributed to the low protein intake.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/2000; 16:291-3.
[show abstract][hide abstract] ABSTRACT: Renal artery stenosis of the transplant kidney occurs in approximately 6% of renal allograft recipients. Severe bilateral renal artery stenosis and unilateral renal artery stenosis to a single functioning kidney have been described as causes of recurrent pulmonary edema in nontransplant patients with normal cardiac function. We report 2 patients with severe transplant renal artery stenosis who presented with recurrent episodes of acute pulmonary edema. Successful revascularization in 1 patient prevented the recurrence of pulmonary edema. In renal allograft recipients who present with unexplained recurrent episodes of acute pulmonary edema, who do not have an obvious cardiac cause, transplant renal artery stenosis should be considered as a possible etiology.
[show abstract][hide abstract] ABSTRACT: Our objective was to study the impact of peritoneal catheter configuration on continuous ambulatory peritoneal dialysis (CAPD)-related infections, mechanical complications, and patient dropout in a prospective randomized trial. Forty consecutive patients who were commencing CAPD were randomized to receive either a double-cuff, Swan neck coiled catheter or a double-cuff, straight Tenckhoff catheter, implanted by surgical technique. There was no significant difference in the peritonitis rate between the two groups. There was a lower rate of exit-site infection in the Swan neck group compared to the straight catheter group (0.29 vs 0.60 episodes/patient-year, p < 0.05). Catheter-tip migration occurred in 3 patients with the straight catheters compared to one patient with the Swan neck catheter. No patient had to discontinue CAPD because of mechanical complications. The number of CAPD patient dropouts was not significantly different between the two groups. The Swan neck configuration resulted in a significant reduction in the rate of exit-site infections. The coiled component of the catheter may lead to fewer episodes of catheter-tip migration. However, catheter configuration did not influence the number of technique failures.
Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis 01/1996; 16 Suppl 1:S333-5. · 2.21 Impact Factor
[show abstract][hide abstract] ABSTRACT: Cyclosporine A (CsA) is an important immunosuppressant in kidney transplantation. Acute CsA nephrotoxicity secondary to high drug levels is a well-recognized complication in the immediate posttransplant period. Cyclosporine A is metabolized in the body by the hepatic cytochrome P-450 enzyme system. We present a case of a hypothyroid patient who developed toxic blood CsA levels and acute nephrotoxicity with standard doses of CsA. A reduction of CsA levels led to an improvement of allograft function. Correction of the hypothyroid state resulted in the normalization of CsA requirements, but overcorrection led to an increased requirement of CsA. Thyroid dysfunction should be considered as an interacting factor in the metabolism of CsA.
American Journal of Kidney Diseases 04/1995; 25(3):503-5. · 5.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: There is an increasing trend towards the use of aminoglycosides in a once-daily dose administration for the treatment of severe infections in nonrenal failure patients. The use of once-daily dose aminoglycoside therapy may be associated with a reduction in toxicity. We performed a prospective randomized study comparing once-daily versus multiple-dose gentamicin in the treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Seventy-three patients with 100 new episodes of peritonitis were enrolled in the study. At presentation of peritonitis, the patients were alternately assigned to receive either intraperitoneal gentamicin at a dose of 40 mg/2 L dialysate administered as a once-daily dose or gentamicin at a dose of 10mg/2 L dialysate administered 4 times per day. All patients also received intraperitoneal vancomycin at a dose of 1 g per week. There were no significant differences in the treatment success (88% vs 82%, p = NS) and relapse (18% vs 20%, p = NS) rates between the once-daily dose and multiple-dose groups. The mean trough serum gentamicin level was higher in the once-daily dose group compared to the multiple-dose group (0.75 +/- 0.72 vs 1.50 +/- 1.40 mg/L). In conclusion, gentamicin administered in a once-daily dose is as effective as multiple-dose administration in the treatment of CAPD peritonitis. The lower gentamicin level with once-daily dose administration may be associated with a reduction in aminoglycoside toxicity.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/1995; 11:179-81.
[show abstract][hide abstract] ABSTRACT: Dyslipidemia is an important risk factor for atherosclerotic vascular disease. Serum lipoprotein (a) [Lp(a)] has been implicated as an independent atherogenic risk factor. We measured serum (Lp(a) levels in our patients and studied its correlations with other lipoproteins and clinical parameters. All stable patients on continuous ambulatory peritoneal dialysis (CAPD) for more than one month were enrolled in the study. Fasting serum Lp(a), total cholesterol, triglycerides, LDL-cholesterol, HDL-cholesterol, apolipoprotein-A and apolipoprotein-B levels were measured on entering the CAPD program and at 3 monthly intervals. One hundred and nine patients (M/F: 65/44, mean age +/- SD: 59.5 +/- 12.0 years) were studied. Fifty-two patients had diabetes mellitus. Age- and sex-matched normals were used as controls. Serum Lp(a) levels were raised in 54.5% of CAPD patients compared to 18.6% of controls (p < 0.01). There was no significant change in Lp(a) levels over time. Serum Lp(a) levels showed positive and negative correlations with LDL-cholesterol and triglycerides, respectively, but not with age, sex, diabetic status, and serum total cholesterol and albumin levels. Thirty-six of 54 (66.7%) patients with serum Lp(a) levels greater than 30 mg/dL had either coronary, cerebral, and/or peripheral vascular disease compared to 30/55 (54.5%) of patients with serum Lp(a) levels less than 30 mg/dL (p = NS). In conclusion, serum Lp(a) levels were raised in a significant proportion of CAPD patients, but there was no significant association with vascular disease.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 01/1995; 11:131-3.
[show abstract][hide abstract] ABSTRACT: Skin mast cell density was determined in two age- and sex-matched groups of patients with end-stage renal failure, one with severe uraemic pruritus (n = 9) and the other without (n = 9). In each group, seven patients were on chronic haemodialysis. In uraemic patients without pruritus, skin mast cell density was similar to that in eight healthy controls (40.1 +/- 10.2 mm2 versus 46.5 +/- 20.6 mm2; P = 0.44), a result also obtained when only the patients on haemodialysis were considered (39.3 +/- 14.7 versus 46.5 +/- 20.6; P = 0.46), showing that haemodialysis per se did not cause mast cell proliferation. In contrast, uraemic patients with itch had significantly higher dermal mast cell counts when compared with those without itch (71.8 +/- 36.4 mm2 versus 40.1 +/- 12.9 mm2; P = 0.01). However, there was no difference in serum parathyroid hormone (PTH) and calcium or phosphate concentrations between the two groups. In addition, there was no significant correlation between dermal mast cell density and serum PTH, calcium or phosphate concentrations. These data suggest that uraemic pruritus may be related to mast cell proliferation in the skin.
Annals of the Academy of Medicine, Singapore 06/1994; 23(3):327-9. · 1.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Staphylococcus aureus nasal carriage has been shown to be associated with an increased risk of S. aureus exit-site infections, but its association with peritonitis is less well established. We performed a four-year prospective study to determine the relationship between S. aureus continuous ambulatory peritoneal dialysis (CAPD)-related infections and nasal carriage. All patients who had been started on CAPD from 1989 to 1992 had regular nose cultures. S. aureus nasal carriage was defined as two of three positive nose cultures. A total of 41 carriers and 105 noncarriers were studied. The rates of S. aureus exit-site infection (0.23 vs 0.09 episode/patient/year, p < 0.005), peritonitis (0.33 vs 0.10 episode/patient/year, p < 0.005), and catheter loss (0.12 vs 0.05, p < 0.01) were significantly higher among the carriers. Life-table analysis showed a significant risk of S. aureus exit-site infection and peritonitis for carriers (p < 0.01). Logistic regression analysis showed that S. aureus nasal carriage was the most important predictive factor for S. aureus peritonitis. In conclusion, our study showed that S. aureus nasal carriage is related to an increased incidence of S. aureus CAPD-related infections.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/1994; 10:163-5.
[show abstract][hide abstract] ABSTRACT: The identification of organisms is important in the treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. We compared two techniques for isolating organisms in CAPD peritonitis. Clinical and microbiologic data on all episodes of peritonitis from 1991-1993 were prospectively recorded. The isolation of organisms from 77 episodes of peritonitis was done using the conventional centrifugation culture method from 1991-1992; the isolation of organisms from 121 episodes of peritonitis was done using the BACTEC method from 1992-1993. The total culture-positive rates were 75% for the BACTEC technique and 58% for the conventional technique (p = 0.05), with a higher isolation rate for gram-negative organisms (36% vs 18%, p < 0.05). In the isolation of organisms from new episodes of peritonitis, the culture-positive rates were significantly higher for the BACTEC than for the conventional technique (82% vs 55%, p < 0.01). The recovery rates of organisms for both techniques were similar for relapse peritonitis. The treatment outcomes of CAPD peritonitis for the two technique groups, and for the culture-positive and culture-negative groups were not significantly different. In conclusion, the BACTEC method yielded a higher rate of positive cultures for CAPD peritonitis, but did not affect treatment outcome of the infections.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/1994; 10:166-8.
[show abstract][hide abstract] ABSTRACT: Tumor markers play an important role in the assessment of patients with some types of malignant tumors. We studied the effects of dialysis and transplantation on the serum levels of five tumor markers; alpha-fetoprotein (AFP), carcino-embryonic antigen (CEA), cancer antigen-125 (CA-125), cancer antigen-19.9 (CA-19.9), and prostate specific antigen (PSA). Serum tumor markers were measured in patients who-had been on dialysis treatment or had a renal transplant for at least one month. Four groups of 30 patients each (hemodialysis, peritoneal dialysis, renal transplant, and normal controls) were studied. Age and sex distribution were comparable between the dialysis and control groups, but the age was significantly younger in the transplant group. Serum AFP and PSA levels were within normal limits in the dialysis and transplant patients. Serum tumor markers, which were raised in the hemodialysis and peritoneal dialysis patients compared to transplant patients and controls, include: CEA (4.5 +/- 2.7 and 5.1 +/- 3.0 vs 1.7 +/- 1.2 and 2.7 +/- 1.2, p < 0.001); CA-125 (41.1 +/- 43.8 and 18.9 +/- 12.7 vs 13.4 +/- 5.7 and 6.1 +/- 4.9, p < 0.001 and p < 0.05); and CA-19.9 (66.0 +/- 60.4 and 66.2 +/- 76.5 vs 20.2 +/- 12.3 and 5.3 +/- 4.5, p < 0.001). Raised CEA, CA-125, and CA-19.9 levels were detected in 37%, 10%, and 53% of peritoneal dialysis patients and 17%, 27%, and 57% of hemodialysis patients. Although the mean serum CEA, CA-125, and CA-19.9 levels were higher in the transplant patients compared to controls.(ABSTRACT TRUNCATED AT 250 WORDS)
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 01/1994; 10:109-11.
[show abstract][hide abstract] ABSTRACT: Nosocomial urinary tract infection (UTI) is an important cause of increased morbidity and mortality in hospitalised patients. The increasing use of broad spectrum antibiotics will result in changes in the microbiological and antibiotic sensitivity pattern of pathogens isolated from nosocomial UTI. We have endeavoured to study the bacteriological pattern of nosocomial UTI and the antibiotic sensitivity patterns of the pathogens concerned. Over a period of one year, a total of 541 patients with 656 episodes of nosocomial UTI were studied. A total of 748 organisms were isolated. The two main complicating factors in nosocomial UTI were urogenital instrumentation (70.4%) and diabetes mellitus (24.2%). Klebsiella species (spp) was the predominant organism isolated (25.0%) and was significantly associated with age and diabetes mellitus. Klebsiella spp in nosocomial UTI showed an overall increase in resistance to antibiotics and multiple antibiotic resistant strains were not uncommon. Escherichia coli was isolated in 17.7% of cases. Streptococcus faecalis was isolated in 10.6% of cases and was significantly associated with instrumentation. Pseudomonas spp was isolated in 8.6% of cases and was generally sensitive to ceftazidime and amikacin. It was associated with systemic malignancies and the use of immunosuppressants.
Annals of the Academy of Medicine, Singapore 12/1993; 22(6):873-7. · 1.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: In view of the increasing concern about methicillin-resistant Staphylococcus aureus (MRSA) infections, we studied the characteristics and outcome of MRSA nasal carriage and infections in our CAPD program. All patients entering into the CAPD program from January 1989 to December 1991 were enrolled into the study. The patients' anterior nares were cultured before the implantation of the catheters. Peritoneal dialysis-related infections were diagnosed based on standard criteria. Data on MRSA nasal carriage, exit-site and tunnel infections and peritonitis were prospectively collected. A total number of 167 patients with 225.9 patient dialysis years were studied with a mean follow-up duration of 16.2 +/- 9.5 months. There were 28 patients with MRSA nasal carriage. The carrier state was unrelated to age, sex and presence of diabetes mellitus. MRSA nasal carriage was associated with a significant increase in the rate of peritonitis (P < 0.01) and exit-site infections (P < 0.01), the number of catheter losses, and CAPD patient dropout (P < 0.001). A total of 30 patients had MRSA infections. In this group, 15 patients had 24 episodes of peritonitis; 20 had 22 episodes of exit-site infections; and 1 had tunnel infection. Fourteen patients had a combination and/or multiple episodes of infections. Treatment of MRSA infections with intraperitoneal vancomycin was unsuccessful in 12 patients (40.0%) resulting in catheter loss. Nine patients (30.0%) dropped out of CAPD after treatment failure for MRSA peritonitis. The patient dropout rate per infection for MRSA infections was comparable to Pseudomonas and fungal infections, but was significantly higher than MSSA infections (P < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)
Kidney International 06/1993; 43(6):1357-62. · 7.92 Impact Factor
[show abstract][hide abstract] ABSTRACT: Breaking-in after catheter implantation may be an important factor in the development of early catheter-related infections in continuous ambulatory peritoneal dialysis (CAPD) patients. We carried out a prospective study comparing two break-in techniques after catheter implantation. All patients entering the CAPD program from March 1991 to December 1992 were enrolled into the study. Data on diabetes mellitus status, Staphylococcus aureus nasal carriage, and peritoneal dialysis-related infections were gathered. After catheter implantation, the patients were assigned to either have their catheter rested until the fourteenth postoperative day (group 1) or immediate use of the catheter for intermittent peritoneal dialysis (group 2). Exit-site care was identical for both groups. A total of 32 patients in group 1 and 74 in group 2 were studied. Age, sex, and S. aureus nasal carriage were not significantly different between the two groups. There were more patients with diabetes mellitus in group 2. Four patients in group 2 dropped out of the CAPD program because of refractory peritonitis. There was no significant difference in the number of exit-site infections between groups 1 and 2. There were more patients who had pericatheter leakage and catheter migration in group 2 compared to group 1, although the difference was not statistically significant.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/1993; 9:236-9.