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Besides defining the appropriate doses of frusemide in uraemic patients, A. Heidland's contribution to the treatment of hypertension in chronic renal failure consisted in the following demonstrations: (1) In patients on chronic haemodialysis, calcium antagonists have a beneficial effect on their glucose intolerance and decreased plasma levels of 25OH vitamin D while their effect on blood lipids is neutral. (2) In 5/6 nephrectomized rats, captopril, verapamil, and metoprolol have the same protective effect on their GFR and tubular secretion of protons, at equal blood-pressure-lowering effect. (3) In rats with streptozotocin-induced diabetes, atrial natriuretic peptide does not play a role in their hyperfiltration. (4) Severe retinopathy is observed in patients with uraemic nephropathies at a much smaller elevation of their blood pressure than in patients with essential hypertension. This article reviews the following points: (1) The role of hypertension in the loss of renal function is convincingly demonstrated only in a few experimental models, and in man only in malignant hypertension and diabetic nephropathy but not in essential hypertension nor in non-diabetic nephropathy. However, preliminary results suggests that antihypertensive treatment may retard the progression of renal disease in normotensive patients (DBP <90 mmHg) with either microalbuminuric diabetes and normal renal function or non-diabetic uraemic nephropathy. (2) Only the ACE inhibitors have been proved to have a specific renal protective effect, independent of their diurnal blood-pressure-lowering effect, both in diabetic nephropathy and in non-diabetic uraemic nephropathy.
Nephrol Dial Transplant 1994
PMID:Hypertension and progression of renal insufficiency. 807 21

Due to inadequate cadaveric and living related organ supply, many end-stage renal disease patients go to third-world countries for living unrelated (paid) kidney transplantation. Thirty-four patients who have had transplantations in two centres in India before coming to our centre for post-transplant care and follow-up are reported in this study. In the post-transplant phase at our centre, the mean follow-up period of the patients was 209.7 +/- 137.3 (range 6-450) days. Fourteen of them, having an uneventful course, were followed on an outpatient clinic basis. The rest of the patients were hospitalized because of the following surgical and/or medical complications, during admission: urinary fistula in two patients; lymphocele in three patients; urinary tract obstruction in two patients; decubitus ulcer in one patient; severe wound infection in one patient; subacute myocardial infarction in one patient; acute irreversible vascular rejection in two patients; urinary tract infection in two patients; pneumonia in two patients; congestive heart failure and severe electrolyte disturbance in two patients; post-transplant diabetes mellitus and ketoacidosis in one patient; cyclosporin nephrotoxicity in two patients; cyclosporin nephro-, hepato-, and neurotoxicity in one patient. Plasmodium falciparum malaria in three patients, generalized mucormycosis infection in one patient, and genitourinary aspergillosis in one patient were seen during the first month. Hepatitis B virus infection followed by chronic active hepatitis was diagnosed in two patients, 2 and 4 months after the operation; and Kaposi's sarcoma was noted in another two patients, 1 and 5 months after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)
Nephrol Dial Transplant 1994
PMID:Living unrelated (paid) kidney transplantation in Third-World countries: high risk of complications besides the ethical problem. 808 44

This study was designed to investigate trained home nurses in the care of elderly and disabled end-stage renal disease (ESRD) patients receiving peritoneal dialysis (PD) in all the patients who entered our home program between January 1989 and December 1992. We trained nursing staff from nursing agencies to do PD. A weekly nursing summary including daily vitals, PD flow sheet, medications, and progress notes was sent to the home program. The trained nurses were also utilized temporarily during acute deterioration of patients or partners resulting in the inability to do PD. Eleven patients were female, 10 were male, with a mean age of 62 years (range 30-81 years). Ten patients (48%) had diabetes mellitus. Thirteen patients performed continuous ambulatory peritoneal dialysis (CAPD) and 8 patients continuous cycling peritoneal dialysis. Five patients required home nurses temporarily for a period of 1-8 weeks until the patients became independent. Two patients were transferred to incenter hemodialysis, one because of insurance and one because of fungal peritonitis. One patient recovered renal function after 22 months of PD. Thirty-three episodes of peritonitis occurred over 417 patient-months (one episode/13 patient-months). Three patients needed catheter removal secondary to Candida peritonitis. Hospitalization rate and duration of stay were lower (1 admission/6 patient-months) than patient-months without home nurses (1/4 patient-months). The main causes of these admissions were diabetic complications (38%), cardiac disease (20%), and peritonitis (14%). In conclusion, our experience suggests that elderly and disabled patients on PD with home nurses have a favorable outcome even with multiple, comorbid conditions.
Adv Perit Dial 1993
PMID:Peritoneal dialysis with trained home nurses in elderly and disabled end-stage renal disease patients. 810 6

This study was designed to investigate the outcome of all elderly patients older than 65 who started peritoneal dialysis (PD) between January 1989 and December 1992. One hundred and twenty end-stage renal disease (ESRD) patients commenced PD at our institution between January 1989 and December 1992. All the patients who started, completed PD training, and remained on PD for more than one month were included in the study. Of these, 30 patients were elderly (more than 65 years old) with a mean age of 72 years (range 66-81 years). The total number of patient-months observed was 2035, of which the elderly represented 454 patient-months. Twenty-five percent (30 of 120 patients) were elderly. The causes of ESRD were diabetes mellitus in 6 patients (20%), glomerulonephritis in 6 (20%), atheroembolic disease in 4 (13.3%), hypertension in 2 (6.7%), and unknown etiology in 10 (33.3%) patients. Sixteen patients performed continuous ambulatory peritoneal dialysis (CAPD) and 14 patients continuous cycling peritoneal dialysis (CCPD). Five patients required private home nurses for multiple medical problems and for PD. Mean duration of peritoneal dialysis per patient was 15 months. Four patients were transferred to incenter hemodialysis, one each because of failure to thrive, insurance, catheter malfunction, and fungal peritonitis. One patient recovered renal function after 22 months of PD. Twenty-one episodes of peritonitis occurred over 454 patient-months (1 episode/22 patient-months). In conclusion, the elderly patients on PD have a favorable outcome even with multiple comorbid conditions.
Adv Perit Dial 1993
PMID:Peritoneal dialysis in elderly end-stage renal disease patients. 810 7

We performed a retrospective chart review of 32 patients on peritoneal dialysis (PD) for longer than 5 months (range 5-64 months) in an attempt to identify risk factors influencing the preservation of renal function. Residual renal function (RRF) was evaluated by measurement of creatinine clearance (Ccr) from 24-hour urine collections. Risk factors examined included age and Ccr at start of PD, presence of diabetes, mean arterial pressure (MAP), diastolic blood pressure (DBP), and peritonitis rate. Multiple regression analysis was performed to determine the correlation of these factors to the rate of decline of Ccr. Loss of RRF in all patients was 0.3 mL/min/month (median 0.2, range 0.04-1.7). The contribution of RRF to total Ccr was 39% (range 12%-72.5%). Patient age, presence of diabetes, MAP, DBP, peritonitis rate, and Ccr at the start of PD had no influence on the rate of RRF loss. Nine patients in the study (28%) had been on PD longer than 2 years and still had significant renal function (mean Ccr 3.3 mL/min), which was 40% of their total weekly Ccr. These results show that PD patients can maintain RRF for extended periods and that RRF contributes substantially to their weekly Ccr. The risk factors evaluated did not influence the rate of renal function loss.
Adv Perit Dial 1993
PMID:Loss of residual renal function in patients on peritoneal dialysis. 810 15

Data comparing peritoneal dialysis (PD)-related infection rates between diabetic and nondiabetic patients on chronic peritoneal dialysis are conflicting. We carried out a prospective study comparing PD-related infection rates between diabetic and nondiabetic patients treated with continuous ambulatory peritoneal dialysis (CAPD) in our center. All patients commencing CAPD between January 1989 and June 1992 were enrolled into the study. Patients were followed up until death, CAPD dropout, or until December 1992. Data on diabetes mellitus status, Staphylococcus aureus nasal carriage, and PD-related infections were gathered. Infection rates were analyzed using life tables and the negative binomial test. One hundred and seven diabetic patients and 72 nondiabetic patients were studied. Patients with diabetes mellitus were not at increased risk of being S. aureus nasal carriers. The peritonitis rate was significantly higher in the diabetic group (1.2 vs 0.8 episodes/patient/year, p < 0.05). The exit-site and tunnel infection, catheter loss, and patient dropout rates were not significantly different between the two groups. Life-table analysis did not show a significant difference in the time to first episode of peritonitis and catheter-related infection.
Adv Perit Dial 1993
PMID:A prospective study of peritoneal dialysis-related infections in CAPD patients with diabetes mellitus. 810 22

Two patients with end-stage renal disease from diabetes mellitus on peritoneal dialysis for 2 or more years developed sterile peritonitis secondary to splenic infarcts with associated peripheral embolic phenomena. The dialysate had WBC counts > 200/microL, of which 70% or more were polymorphonuclear cells, and RBC counts of 60/microL or less, although transient hemoperitoneum occurred in both patients. Extensive atherosclerotic vascular disease as well as hematologic abnormalities were also present in both patients. One patient had polycythemia due to decreased plasma volume. The other patient had evidence of dysfibrinogenemia. The patients responded well to anticoagulation with warfarin. When the warfarin was discontinued, recurrent emboli occurred in both patients. Splenic infarct should be included in the differential diagnosis of diabetic patients with atherosclerotic disease who present with sterile peritonitis that does not respond to antibiotic therapy, especially if hemoperitoneum occurs even transiently. The diagnosis can be confirmed with CT scan of the abdomen. Warfarin therapy is effective in preventing recurrent embolic phenomena, but may need to be continued indefinitely.
Adv Perit Dial 1993
PMID:Splenic infarct presenting as sterile peritonitis with peripheral embolic phenomena. 810 24

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.
Adv Perit Dial 1993
PMID:A retrospective view of factors that affect catheter healing: four years of experience. 810 28

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.
Adv Perit Dial 1993
PMID:Breaking-in after the insertion of Tenckhoff catheters: a comparison of two techniques. 810 33

We review our experience with hypertonic saline compress therapy in 17 patients with complicated peritoneal dialysis catheter exit-site infections (ESIs). Compresses consisted of exit-site application of 4-5 gauze pads soaked with warm 3% saline for 5-10 minutes, three times daily, for 2-4 weeks, followed by once-daily use thereafter. The mechanism of action involves inhibition of bacterial growth by a hypertonic medium. Eleven patients with cultures positive for Staphylococcus aureus or Pseudomonas were treated with local exist-site measures (cleansers, antiseptics, antibiotic ointments). Therapy, which included multiple courses of systemic antibiotics, failed in 8 patients; in 3 patients, who were intolerant to antibiotics, ESI remained unresolved after local care only. Six patients with culture-negative ESIs received no systemic antibiotics and were unimproved following local therapy. Factors associated with therapy failure included malnutrition, diabetes, obesity, and dermal sensitization and injury associated with prolonged topical agent use. Following hypertonic saline compress therapy, we observed resolution of ESI in all patients without recurrence for follow-up intervals of 3-12 months (mean 6.5 months). Advantages of this therapy include excellent patient acceptance, ease of use, lack of adverse effects on exit site, adjacent skin, catheter or systemic reaction, and minimal expense. Future potential applications include routine daily use for infection prophylaxis and as therapy combined with antibiotics for established ESIs.
Adv Perit Dial 1993
PMID:Hypertonic saline compresses: therapy for complicated exit-site infections. 810 36


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