High-Volume Peritoneal Dialysis in Acute Kidney Injury: Indications and Limitations

Background and objectives Peritoneal dialysis is still used for AKI in developing countries despite concerns about its limitations. The objective of this study was to explore the role of high-volume peritoneal dialysis in AM patients in relation to metabolic and fluid control, outcome, and risk factors associated with death.Design, setting, participants, & measurements A prospective study was performed on 204 AKI patients who were assigned to high-volume peritoneal dialysis (prescribed Kt/V=0.60/session) by flexible catheter and cycler; 150 patients (80.2%) were included in the final analysis.Results Mean age was 63.8 +/- 15.8 years, 70% of patients were in the intensive care unit, and sepsis was the main etiology of AKI (54.7%). BUN and creatinine levels stabilized after four sessions at around 50 and 4 mg/dl, respectively. Fluid removal and nitrogen balance increased progressively and stabilized around 1200 ml and -1 g/d after four sessions, respectively. Weekly delivered Kt/V was 3.5 +/- 0.68. Regarding AKI outcome, 23% of patients presented renal function recovery, 6.6% of patients remained on dialysis after 30 days, and 57.3% of patients died. Age and sepsis were identified as risk factors for death. In urine output, increase of 1 g in nitrogen balance and increase of 500 ml in ultrafiltration after three sessions were identified as protective factors.Conclusions High-volume peritoneal dialysis is effective for a selected AKI patient group, allowing adequate metabolic and fluid control. Age, sepsis, and urine output as well as nitrogen balance and ultrafiltration after three high-volume peritoneal dialysis sessions were associated significantly with death. Clin J Am Soc Nephrol 7: 887-894, 2012. doi: 10.2215/CJN.11131111

Markers of uremia and pericardial effusion in peritoneal dialysis

Inadequate dialysis causes accumulation of toxic residues that may lead to the development of dialysis-associated pericardial effusion, but several other factors could be associated with this abnormality. The purpose of this study was to evaluate clinical risk factors to asymptomatic pericardial effusion in peritoneal dialysis.This cross-sectional study included 34 patients aged a parts per thousand yen18 years on peritoneal dialysis for at least 3 months, who showed no symptomatic pericardial effusion, hepatic cirrhosis, neoplasias, lupus or amputations, none in minoxidil use. Asymptomatic pericardial effusion was diagnosed by echocardiography. Risk factors were evaluated by logistic regression and Roc curve. Significance level was set at P < 0.05.Patient age was 51 +/- A 15.9 years. of the 34 patients enrolled, 16 were men and 11 diabetic. Five of them presented pericardial effusion. Logistic regression identifies low hemoglobin level (RR 0.454 CI 95%: 0.225-0.913; P = 0.027), low phase angle (RR 0.236 CI 95%: 0.057-0.984; P = 0.048) and low Kt/V (RR 0.001 CI 95%: 0.0-0.492; P = 0.03) as risk factors to pericardial effusion. Roc curve showed that hemoglobin levels below 12.2 g/dL, Kt/V lower than 1.9 and phase angle lower than 4.5A degrees were the best cutoffs to predict pericardial effusion. Four patients showed these three parameters in the unfavorable range, and all these four patients presented pericardial effusion. The other patient with pericardial effusion had two of these parameters reduced.These findings corroborate the hypothesis that uremia plays a significant role in the pathogenesis of dialysis-associated pericardial effusion.

Geographic and Educational Factors and Risk of the First Peritonitis Episode in Brazilian Peritoneal Dialysis Study (BRAZPD) Patients

Background and objectives Peritonitis remains as the most frequent cause of peritoneal dialysis (PD) failure, impairing patient's outcome. No large multicenter study has addressed socioeconomic, educational, and geographic issues as peritonitis risk factors in countries with a large geographic area and diverse socioeconomic conditions, such as Brazil.Design, setting, participants, & measurements Incident PD patients recruited from 114 dialysis centers and reporting to BRAZPD, a multicenter observational study, from December 2004 through October 2007 were included. Clinical, dialysis-related, demographic, and socioeconomic variables were analyzed. Patients were followed up until their first peritonitis. Cox proportional model was used to determine independent factors associated with peritonitis.Results In a cumulative follow-up of 2032 patients during 22.026 patient-months, 474 (23.3%) presented a first peritonitis episode. In contrast to earlier findings, PD modality, previous hemodialysis, diabetes, gender, age, and family income were not risk predictors. Factors independently associated with increased hazard risk were lower educational level, non-white race, region where patients live, shorter distance from dialysis center, and lower number of patients per center.Conclusions Educational level and geographic factors as well as race and center size are associated with risk for the first peritonitis, independent of socioeconomic status, PD modality, and comorbidities. Clin J Am Soc Nephrol 6: 1944-1951, 2011. doi: 10.2215/CJN.11431210

Peritoneal Dialysis-Related Peritonitis Due to Staphylococcus aureus: A Single-Center Experience over 15 Years

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Relevância do estado de hidratação na interpretação de parâmetros nutricionais em diálise peritoneal

OBJETIVO: Identificar determinantes do estado de hidratação de pacientes em diálise peritoneal crônica, bem como investigar os efeitos da sobrecarga líquida sobre o estado nutricional. MÉTODOS: Foi feito estudo transversal, realizado em 2006, avaliando 27 pacientes em diálise peritoneal crônica, acompanhados no Hospital das Clínicas da Faculdade de Medicina de Botucatu (SP), quanto a parâmetros clínicos, dialíticos, laboratoriais, antropométricos e de bioimpedância elétrica. Para avaliar a influência de parâmetros sobre o estado de hidratação empregou-se modelo de regressão linear múltipla. A amostra foi estratificada quanto ao estado de hidratação pela relação entre água extracelular e água corporal total (0,47 para homens e 0,52 para mulheres), parâmetros obtidos por meio de bioimpedância elétrica. Comparações foram realizadas por análise de covariância, Mann-Whitney, Qui-quadrado ou teste exato de Fisher. Considerou-se significância estatística quando p≤0,05. RESULTADOS: Pacientes com maior volume urinário e em modalidade dialítica automatizada apresentaram melhor estado de hidratação. Pacientes com maior sobrecarga líquida, comparados àqueles com menor sobrecarga, apresentaram menor ângulo de fase (M=4,2, DP=0,9 vs M=5,7, DP=0,7º; p=0,006), menor albumina (M=3,06, DP=0,46 vs M=3,55, DP=0,52g/dL; p=0,05) e maior % prega cutânea tricipital (M=75,3, DP=36,9 vs M=92,1, DP=56,9%; p=0,058), sem outras evidências antropométricas. CONCLUSÃO: Pode-se sugerir que os níveis reduzidos de albumina e ângulo de fase nos pacientes com maior sobrecarga líquida não estiveram relacionados a pior estado nutricional. Para o diagnóstico nutricional em vigência de sobrecarga líquida, deve-se considerar o conjunto de variáveis obtidas por diversos métodos, buscando relacioná-las e interpretá-las de maneira abrangente, possibilitando um diagnóstico nutricional fidedigno.

Killing of Paracoccidioides brasiliensis yeast cells by IFN-gamma and TNF-alpha activated murine peritoneal macrophages: evidence of H(2)O(2) and NO effector mechanisms

Paracoccidioidomycosis is a deep mycosis, endemic in Latin America, caused by Paracoccidioides brasiliensis. Macrophage activation by cytokines is the major effector mechanism against this fungus. This work aimed at a better understanding of the interaction between yeast cells-murine peritoneal macrophages and the cytokine signals required for the effective killing of high virulence yeast-form of P. brasiliensis. In addition, the killing effector mechanisms dependent on the generation of reactive oxygen or nitrogen intermediates were investigated. Cell preincubation with IFN-gamma or TNF-alpha, at adequate doses, resulted in effective yeast killing as demonstrated in short-term (4-h) assays. Both, IFN-gamma and TNF-alpha activation were associated with higher levels of H(2)O(2) and NO when compared to nonactivation. Treatment with catalase (CAT), a H(2)O(2) scavenger, and N(G)-monomethyl-L-arginine (L-NMMA), a nitric oxide synthase inhibitor, reverted the killing effect of activated cells. Taken together, these results suggest that both oxygen and L-arginine-nitric oxide pathways play a role in the killing of highly virulent P. brasiliensis.

Effect of age and abomasal puncture on peritoneal fluid, hematology, and serum biochemical analyses in young calves

The goals of this study were to evaluate techniques for collection of peritoneal fluid from calves, establish reference ranges for fibrinogen in peritoneal fluid during the 1st month of life, and determine if abomasal puncture would alter peritoneal fluid or hematologic variables. Twenty-two healthy Holstein calves underwent 3 peritoneal fluid collections on day 1, day 15, and day 30 of age. Fibrinogen concentration in peritoneal fluid was 0.20 g/dL and 0.10 g/dL (P < .05) for day 1 and day 30, respectively, and 0.10 at day 15 (P > .05) for calves without abomasal puncture. Plasma fibrinogen concentration was 0.60 g/dL and 0.70 g/dL (P < .05) for days 15 and 30, respectively, in calves without abomasal puncture. There were no significant differences (P <= .05) in peritoneal fluid and peripheral blood total protein and fibrinogen concentrations, specific gravity, total and differential cell count, or erythrocyte counts between calves with or without abomasal puncture. We concluded that the reference ranges established for fibrinogen and total protein concentration are important for accurate evaluation of peritoneal fluid in calves for further comparison with similar-aged animals with gastrointestinal-tract or abdominal-cavity disease. Additionally, accidental abomasal puncture does not alter values of fibrinogen, total protein, and nucleated cell Count in peritoneal fluid and does not cause apparent clinical abnormalities.

Evaluation of cytologic and biochemical variables in blood, plasma, and peritoneal fluid from calves before and after umbilical herniorrhaphy

Objective-To establish reference intervals for cytologic and biochemical variables in peritoneal fluid, whole blood, and plasma in calves with congenital umbilical hernias (CUHs) before and after herniorrhaphy and to assess whether those variables in calves with CUHs were altered, compared with findings in clinically normal calves.Animals-20 Holstein calves with or without a CUH.Procedures-10 calves with CUHs underwent herniorrhaphy. Blood and peritoneal fluid samples from all 20 calves were collected for cytologic and biochemical analyses on days 0 (before surgery), 1, 3, 5, 7, and 15. Data from the 2 groups were compared.Results-Reference intervals for the variables of interest were established for each group, Before surgery, calves with CUHs had significantly greater plasma total protein concentration and creatine kinase (CK) and aspartate aminotransferase activities and peritoneal fluid specific gravity values, compared with values for calves without CUHs. At various time points after surgery, peritoneal fluid total protein concentration; fibrinogen concentration; nucleated cell, polymorphonuclear cell, and lymphocyte counts; specific gravity; and lactate dehydrogenase, aspartate aminotransferase, and CK activities in calves with CUHs were significantly different from values in calves without CUHs. Some plasma and blood variables leg, total protein concentration, neutrophil count, and CK activity were significantly different between the 2 groups.Conclusions and Clinical Relevance-Values of certain cytologic and biochemical variables in peritoneal fluid, blood, and plasma were different between calves with and without CUHs. Thus, determination of reference intervals for these variables is important for interpreting diagnostic test results in calves with CUHs. (Am J Vet Res 2009;70:423-432)

Experimental peritonitis in horses: peritoneal fluid composition

Dezesseis eqüinos adultos foram aleatoriamente divididos em quatro grupos de quatro animais que receberam inoculação intraperitoneal das seguintes suspenções: grupo I, 100×10(7) unidades formadoras de colônias (CFU) de E. coli diluídas em 500ml de solução salina a 0,9%; grupo II, 100×10(7) CFU de Bacteroides fragilis em 500ml de solução salina a 0,9%; grupo III, 100×10(7) CFU de E. coli combinados com 100×10(7) CFU de B. fragilis em 500ml de solução salina a 0,9%; grupo IV, 500ml de solução salina a 0,9%. Observou-se aumento significativo do número de leucócitos no líquido peritoneal quatro horas após as inoculações dos animais dos grupos I e II, e oito horas após as inoculações dos animais do grupo III. A contagem mais elevada foi de 516×10³ leucócitos/mm³. Aumentos significativos nas concentrações de fibrinogênio (1g/dl) e proteína total (9,1%) foram também observados. Eqüinos inoculados com culturas puras, tanto de E. coli quanto de B. fragilis, apresentaram peritonites mais brandas e autolimitantes, enquanto que eqüinos inoculados com associação das duas bactérias apresentaram alterações laboratoriais com maior intensidade e duração.

Endotoxemia por lipopolissacarídeo de Escherichia coli, em eqüinos: efeitos de antiinflamatórios nas concentrações sérica e peritoneal do fator de necrose tumoral alfa (TNF-alfa)

Avaliou-se a inibição da produção do fator de necrose tumoral alfa (TNF-alfa) devido ao pré-tratamento com antiinflamatório esteroidal (dexametasona) e não esteroidal (diclofenaco sódico) em eqüinos com endotoxemia induzida experimentalmente. Foram utilizados 15 cavalos machos não castrados, distribuídos em três grupos de cinco animais: controle (C), diclofenaco sódico (DS) e dexametasona (DM). A endotoxemia subletal foi induzida pela infusão intravenosa (IV) de 0,1mg/kg/pv de lipopolissacarídeo (LPS) de Escherichia coli 055:B5, administrado em 250ml de solução estéril de cloreto de sódio a 0,9%, durante 15min. Os cavalos do grupo-controle foram tratados com solução de cloreto de sódio a 9% IV. Nos animais do grupo DS, administraram-se, por via oral, 2,2mg/kg de diclofenaco sódico e, nos do grupo DM, 1,1mg/kg de dexametasona IV, respectivamente, 60 e 30min antes da infusão da endotoxina. Mensurou-se, por meio de ensaio de toxicidade com células da linhagem L929, a concentração de TNF-alfa no soro e no líquido peritoneal às 0, 1¼, 3 e 6 horas após injeção do LPS. No grupo-controle, observou-se aumento significativo de TNF-alfa sérico, em relação ao valor basal e aos grupos DS e DM, 1,15 horas após a indução da endotoxemia. No líquido peritoneal, as concentrações observadas estavam abaixo daquelas da curva padrão de TNF-alfa, não havendo diferença entre os grupos (P>0,05).

Predictive factors of outcome following staphylococcal peritonitis in continuous ambulatory peritoneal dialysis

Background and aims: Staphylococcus epidermidis and other coagulase-negative staphylococci (CoNS) are the most common agents of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Episodes caused by Staphylococcus aureus evolve with a high method failure rate while CoNS peritonitis is generally benign. The purpose of this study was to compare episodes of peritonitis caused by CoNS species and S. aureus to evaluate the microbiological and host factors that affect outcome. Material and methods: Microbiological and clinical data were retrospectively studied from 86 new episodes of peritonitis caused by staphylococci species between January 1996 and December 2000 in a university dialysis center. The influence of microbiological and host factors (age, sex, diabetes, use of vancomycin, exchange system and treatment time on CAPD) was analyzed by logistic regression model. The clinical outcome was classified into two results (resolution and non-resolution). Results: the odds of peritonitis resolution were not influenced by host factors. Oxacillin susceptibility was present in 30 of 35 S. aureus lineages and 22 of 51 CoNS (p = 0.001). There were 32 of 52 (61.5%) episodes caused by oxacillin-susceptible and 20 of 34 (58.8%) by oxacillin-resistant lineages resolved (p = 0.9713). of the 35 cases caused by S. aureus, 17 (48.6%) resolved and among 51 CoNS episodes 40 (78.4%) resolved. Resolution odds were 7.1 times higher for S. epidermidis than S. aureus (p = 0.0278), while other CoNS had 7.6 times higher odds resolution than S. epidermidis cases (p = 0.052). Episodes caused by S. haemolyticus had similar resolution odds to S. epidermidis (p = 0.859). Conclusions: S. aureus etiology is an independent factor associated with peritonitis non-resolution in CAPD, while S. epidermidis and S. haemolyticus have a lower resolution rate than other CoNS. Possibly the aggressive nature of these agents, particularly S. aureus, can be explained by their recognized pathogenic factors, more than antibiotic resistance.

Identification and antimicrobial susceptibility of Staphylococcus from home-treated peritoneal dialysis patients

Staphylococcus aureus is the main agent of infections during peritoneal dialysis (PD). The presence of S. aureus in the nasal cavity has been extensively studied and suggested as a risk factor of dialysis-related infections, whereas coagulase-negative Staphylococcus (CNS) species are frequently considered part of the normal human microbiota. The aim of this study was to identify Staphylococcus in the nasal cavity, pericatheter skin and peritoneal effluent from PD patients, as well as to evaluate the antimicrobial activity evolution in vitro. Thirty-two chronic PD patients were observed during 12 months and had nasal and pericatheter skin samples collected for culture. When peritonitis was detected, samples were also collected from the peritoneal effluent for culture. The activity of several antimicrobial drugs (penicillin G, oxacillin, cephalothin, ofloxacin, netilmicin and vancomycin) against different Staphylococcus species was measured by using the agar drug diffusion assay (Kirby-Bauer method). Staphylococcus was separated into S. aureus, S. epidermidis and other CNS species in order to determine the in vitro resistance level. S. epidermidis resistance to oxacillin progressively increased during the study period (p < 0.05). Resistance to ofloxacin was inexpressive, whereas resistance to netilmicin and vancomycin was not detected. of the oxacillin-resistant species (n = 74), 83% were S. epidermidis, 13% other CNS and 4% S. aureus (p < 0.05). Regarding multidrug resistant strains (n = 45), 82% were S. epidermidis, 13% other CNS, and 5% S. aureus (p < 0.05). This study shows the relevance of resistance to oxacillin and CNS multi-drug resistance, particularly concerning S. epidermidis, in PD patients.

Morphological alteration of peritoneal mast cells and macrophages in the mouse peritoneal cavity during the early phases of an allergic inflammatory reaction

We investigated the presence of mast cell granules in macrophages following an in vivo model of an allergic reaction. Injection of ovalbumin (100 mug) into the peritoneal cavity of sensitised mice produced a rapid (within 2 h) influx of neutrophils followed by a slower (after >4 h) eosinophil migration. Ovalbumin treatment induced a high incidence (similar to 50%) of mast cell degranulation compared to control phosphated-buffered saline-treated mice. The majority (similar to 90%) of peritoneal macrophages contained mast cell granules as early as 2 It post-ovalbumin, with lower values at later time-points, as determined by staining with Toluidine blue and Berberine sulphate. This was confirmed by electron microscopy which enabled us to identify the complex mast cell granule sub-structural components in macrophage phagosomes. In conclusion, we used histochemical and ultrastructural analyses to show that mast cell granules become internalised with macrophages during the early stages of an experimental allergic reaction. (C) 2001 Academic Press.

Exame do fluido peritoneal e hemograma de eqüinos submetidos à laparotomia e infusão intraperitoneal de carboximetilcelulose

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)