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F O Finkelstein

Publications and source records attributed to F O Finkelstein.

81 records · Page 5Linked to original sources
PubMedDate not supplied

Effect of duration of chronic peritoneal dialysis therapy on the development of peritonitis.

OBJECTIVE: Long-term chronic peritoneal dialysis (CPD) therapy has been associated with alterations in peritoneal membrane structure and peritoneal macrophage function. We thus reviewed our experience with the development of peritonitis among patients maintained on CPD therapy for various time periods to determine if the spectrum of organisms, rates of peritonitis, and outcome changed with the duration of CPD therapy. SETTING AND PATIENTS: Patients maintained on CPD therapy in our out-patient unit in New Haven, Connecticut. DESIGN: Retrospective review of the charts of patients maintained on CPD therapy (HomeChoice Cycler or Ultrabag, Baxter, McGaw Park, IL, U.S.A.) between 1 January 1997 and 31 March 1998. These patients were divided into three groups: group 1, patients maintained on CPD therapy < or = 12 months; group 2, patients maintained on CPD therapy for 13-36 months; and group 3, patients maintained on CPD therapy for > or = 37 months. RESULTS: The study included 256 patients: 101 patients in group 1, 110 patients in group 2, and 45 patients in group 3. All groups of patients were similar in age. There were significantly fewer Caucasians and fewer males in group 3 in comparison to groups 1 and 2. The incidence of diabetes mellitus, coronary artery disease, and peripheral vascular disease was significantly lower among patients in group 3 in comparison to groups 1 and 2. There were 155 episodes of peritonitis during the study period for an overall rate of 1 episode in 18.7 patient-months. The overall, gram-positive, and gram-negative rates of peritonitis were not significantly different among the patients in groups 1, 2, and 3. There were more episodes of Staphylococcus aureus peritonitis among patients in group 3 in comparison to group 2 (1 episode in 59.6 vs 1 episode in 280.2 patient-months, respectively). Two weeks after the development of peritonitis, 94.6% of the patients in group 3 continued CPD therapy, while 79.4% of the patients in group 1 continued CPD therapy (p < 0.05). No patient in group 3 transferred to hemodialysis, while 10.3% and 8.2% of the patients in groups 1 and 2 transferred to hemodialysis (p < 0.05). The death rate 2 weeks after the onset of peritonitis was 10.3%, 9.8%, and 5.4% in groups 1, 2, and 3, respectively (p = NS). CONCLUSIONS: Despite the immunological and morphological changes that occur in the peritoneal cavity with increased time on CPD therapy, there was no difference in the overall, gram-positive, or gram-negative rates of peritonitis for patients maintained on CPD therapy for various time periods. Patients in group 3 continued CPD therapy more often than did patients in group 1. Patients in group 3 transferred to hemodialysis less often than did the remaining patients in the study period. The incidence of death was not significantly different for the three groups of patients.

Female↗
PubMedDate not supplied

Incidence of peritonitis in chronic peritoneal dialysis patients infused with intravenous iron dextran.

BACKGROUND: The Dialysis Outcomes Quality Initiative (DOQI) guidelines, published in 1997, emphasize the need for careful monitoring of iron stores and for provision of adequate iron replacement therapy to achieve target goals of hemoglobin concentration in end-stage renal disease (ESRD) patients, especially those treated with recombinant erythropoietin (rHuEPO). Intravenous iron dextran (IVID) therapy, which has long been used in hemodialysis patients, is increasingly being used in chronic peritoneal dialysis (CPD) patients. In 1997, we began using this form of iron therapy for our CPD patients. However, because considerable data exists to show a relationship between iron metabolism and acute infections, we questioned whether IVID infusion placed our patients at greater risk for peritonitis, the leading cause of death and patient drop-out from CPD therapy. OBJECTIVE: To evaluate the relationship between iron and infection, we studied episodes of peritonitis in CPD patients who were infused with IVID. DESIGN: In a retrospective study of adult CPD patients who received IVID during 1998, we investigated the occurrence of peritonitis episodes and the spectrum of causative organisms. Patients with a hemoglobin level of < 12.5 g/dL who also had a ferritin level < 100 ng/mL or a transferrin saturation level < 20% (or both) and who did not respond to oral iron therapy, were administered between 0.5 g and 1.0 g of IVID in an outpatient hospital setting. We calculated the expected and observed number of peritonitis episodes in these patients within 30, 60, and 90 days after infusion of IVID. RESULTS: During the study period, 56 patients received 77 doses of IVID, with 14 patients requiring 2 or more infusions. Of the 77 doses, 71 were given as a 1-g bolus. The IVID was well tolerated by all patients. Within 90 days of IVID administration, 14 patients developed peritonitis: 6 episodes occurred within 30 days, 7 episodes occurred between 31 and 60 days, and 1 episode occurred between 61 and 90 days after the IVID dosing. The peritonitis rate for patients not receiving IVID was 1 episode per 13.7 patient-months. Taking this rate as the "expected" rate, the expected number of episodes of peritonitis for the study population was 5.6 episodes within 30 days, 11.2 episodes within 60 days, and 16.8 episodes within 90 days following IVID administration. The difference between the expected and observed rates of peritonitis in patients who were dosed with IVID was not statistically different. The spectrum of organisms seen in the peritonitis episodes in the study population was not significantly different from that seen in the peritonitis episodes in our CPD unit population. CONCLUSIONS: There is evidence that IVID infusion therapy can improve anemia and reduce rHuEPO requirements in CPD patients, usually without adverse reaction and without exposing patients to an increased risk of peritonitis. More research is needed in the area of potential increased risk of infection in ESRD patients who are (1) infused with large doses of IVID, and (2) iron-overloaded.

Female↗
PubMedDate not supplied

Erectile dysfunction in chronic peritoneal dialysis patients: incidence and treatment with sildenafil.

OBJECTIVES: Sexual and erectile dysfunction (ED) have been reported to occur frequently in male patients with end-stage renal disease maintained on dialysis. Numerous etiologies for this ED have been suggested. Although a variety of therapies for the ED of the dialysis patient have been suggested, most clinicians indicate that patients report a poor response to therapy. Recently, sildenafil has been reported to be beneficial in treating patients with ED of both organic and psychogenic causes. The present study was designed to document the incidence of ED in male patients maintained on chronic peritoneal dialysis (CPD) and to determine the efficacy of prescribing sildenafil therapy to treat their ED. METHODS: All male patients in our CPD unit were notified by letter of the availability of sildenafil as a treatment modality for ED. A sexuality/erectile dysfunction assessment was conducted in all male patients by their primary nephrologist. Patients who reported ED and who had no medical contraindication to sildenafil were offered this therapy. Those patients who were interested in this treatment were interviewed by a social worker, and patients were asked to complete the International Index of Erectile Function questionnaire. Sildenafil was prescribed at a starting dose of 25 mg and increased to a maximum of 100 mg during a 12-week study trial. Patients were re-evaluated 6 and 12 weeks after the start of therapy. RESULTS: There were 68 male patients maintained on CPD at the time of the study. Mean age of all patients was 60.8 +/- 15.3 years and mean duration on PD was 32.6 +/- 25.6 months. Thirty-three patients had diabetes, 66 hypertension, 35 peripheral vascular disease, and 32 coronary artery disease. Thirty-two of 68 male patients in the CPD unit were assessed to have ED. Only 17 of the 32 patients expressed interest in pursuing sildenafil therapy. Two of these patients were excluded because they were receiving nitrate therapy. Of the 15 patients who agreed to take sildenafil, only 6 completed the 12-week study. Two of these patients responded to sildenafil. CONCLUSION: Erectile dysfunction is common in male patients maintained on CPD. Only about half of patients with ED in the present study were willing to consider sildenafil therapy to treat the ED and, of those who agreed to treatment, only a minority completed the 12-week trial; 2 of these 6 patients reported a satisfactory response.

Erectile Dysfunction↗
PubMedDate not supplied

Structural and functional adaptation after reduction of nephron population.

This review of adaptive changes in renal structure and function in subjects with reduced renal mass has two primary goals. One is to provide a description of the remarkable compensatory increases in glomerular filtration rate (GFR), and renal blood flow, at the level of individual nephrons, and the alterations in water and electrolyte transport by tubular epithelium. These processes preserve fluid and electrolyte balance in subjects with progressive renal failure, until whole kidney GFR is reduced to about 20 percent of normal, and provide the basis for conservative clinical medical management. The other aim is an attempt to provide an understanding of the mechanisms involved in compensatory adaptation, since this information, in addition to amplifying our understanding of renal transport processes, helps to elucidate the functional limitations placed on subjects with renal insufficiency. An attempt has been made to analyze both clinical observations and relevant experimental models and an effort has been made to correlate renal function with different patterns of renal injury.

Cations, Divalent↗
PubMedDate not supplied

Continuous ambulatory peritoneal dialysis: experience with 22 unselected patients with renal failure.

The present study describes our experience with CAPD in an unselected group of patients presenting with endstage renal failure. Twenty-three consecutive patients were offered CAPD, in-center, and home hemodialysis. Twenty-two patients selected CAPD, including 14 patients more than 60 years of age, four patients with diabetes, and one with multiple myeloma. CAPD training was performed in an out-of-hospital office facility. One patient returned to hemodialysis following the development of resistant Pseudomonas peritonitis, two patients died of a myocardial infarction, and one patient died with a GI bleed. The other 18 patients are doing well. Assessment of 17 patients maintained on therapy for four months or more revealed that the patients are less depressed, less organic, and have fewer physical symptoms than previously reported for a comparable group of patients maintained on hemodialysis for a similar period of time. In conclusion, CAPD can be successfully employed, at least for the initial months of therapy, to treat the vast majority of patients with endstage renal disease. CAPD training and follow-up care can be provided in an out-of-hospital office facility.

Adult↗
PubMedDate not supplied

Effect of nitroprusside on peritoneal dialysis clearances.

We have studied the effect of intraperitoneal nitroprusside on small (urea) and middle (vitamin B12) molecule dialysis clearances in patients maintained on chronic peritoneal dialysis. Clearances were measured in six patients during the addition of 6 mg of nitroprusside to three and seven consecutive, hourly two-liter exchanges during the course of a routine dialysis treatment. Results indicate that clearances of urea and B12 both increased about 35 percent with the addition of the vasodilator for three exchanges. Clearances immediately returned to baseline values when administration of the vasodilator was discontinued. Addition of the drug to seven consecutive exchanges resulted in a sustained 35 percent increment in clearances. We conclude that addition of 6 mg of nitroprusside to peritoneal dialysis solution can result in a significant increment in both small and middle molecule clearances. Maintenance of the higher clearances requires sustained administration of the drug, which can be tolerated for at least six exchanges with no adverse side effects.

Ferricyanides↗
PubMedDate not supplied

Continuous peritoneal dialysis-associated peritonitis of nosocomial origin.

OBJECTIVE: To describe our experience with nosocomial continuous peritoneal dialysis (CPD)-associated peritonitis focusing on the incidence, possible risk factors, spectrum of organisms, and outcome. DESIGN: Retrospective review of the medical records of our CPD patients admitted to an acute-care hospital between November, 1993 and December, 1994. SETTING: University-associated acute-care hospitals in New Haven, Connecticut. PATIENTS: One hundred and eighty-eight patients maintained on CPD therapy and admitted to an acute-care hospital. RESULTS: Nineteen patients (5%) developing nosocomial peritonitis (NP) were identified from the 408 admissions occurring during the study period. Patients developing NP were older than the hospitalized CPD patients not developing NP (65.5 +/- 14.6 vs 58.4 +/- 14.7 years, p < 0.05). Comorbid diseases including diabetes, peripheral vascular disease, gastrointestinal disease, cardiovascular disease, and human immunodeficiency virus seropositivity were not more common in the patients developing NP. Patients developing NP were hospitalized significantly longer than the CPD patients not developing NP (39.5 +/- 46.5 days vs 12.7 +/- 12.4 days, p < 0.001). The mean serum albumin was lower in the NP patients than in the CPD patients not developing NP (2.35 +/- 0.52 g/dL vs 3.02 +/- 0.60 g/L, p < 0.001). Antecedent antibiotic use and performance of invasive procedures were noted in 89% and 68% of the patients developing NP, respectively. Staphylococcal species, enterococcal species, and gram-negative organisms accounted for 26%, 21%, and 53% of the episodes of NP, respectively. Furthermore, two strains of Enterococcus resistant to vancomycin were cultured. Eight patients developing NP expired, 8 patients continued CPD therapy, 2 patients transferred to hemodialysis, and one patient recovered renal function. CONCLUSION: We conclude that NP is uncommon. Increased age, increased length of hospital stay, and hypoalbuminemia may predispose patients to the development of NP. Further studies with case controls should help to clarify whether antecedent antibiotics or prior performance of invasive procedures predispose patients to the development of nosocomial peritonitis. The spectrum of organisms accounting for NP is different than the spectrum of organisms causing community-acquired CPD-associated peritonitis. Some of these organisms may be resistant to standard antibiotic therapies. Patients developing NP do poorly, with 42% expiring while being treated for NP.

Age Factors↗