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K D Nolph

Publications and source records attributed to K D Nolph.

At least 19 recordsLinked to original sources
PubMed1992

Risk of peritonitis and technique failure by CAPD connection technique: a national study.

Peritonitis has been a leading complication of long-term therapy with continuous ambulatory peritoneal dialysis (CAPD). This study was designed to evaluate the risk of peritonitis and technique failure according to the initial CAPD connection technique. Patients from all U.S. facilities starting CAPD therapy at home between January 1 and June 30, 1989 were followed for up to 21 months on the initial CAPD connection technique to change in technique or dialytic modality, to transplantation, death or loss to follow-up. Patients were grouped into standard connection techniques (SCT) (N = 1,133), Y-set (N = 1,067), standard UV set (N = 916) and O-set (N = 167). The time to first peritonitis episode was analyzed actuarially and by using the Cox proportional hazards model which adjusted for age, sex, race, cause of ESRD, CAPD program size and ESRD therapy prior to CAPD. Peritonitis occurred on average at 9.0 month intervals with SCT, 15.0 months with Y-set, 13.4 with standard UV and 9.4 with O-set. The relative risk (RR by Cox analysis) of first peritonitis compared to SCT was 0.60 (40% lower) for the Y-set (P less than 0.01), 0.75 for standard UV (P less than 0.01), and similar to SCT (RR = 0.96) for the O-set (NS), all else being equal. Analysis time to second (N = 1,271) peritonitis episode gave similar results as did analysis of time to CAPD technique failure. Significantly higher RR of peritonitis and technique failure was observed for younger and black patients. These findings suggest the utilization of connection techniques with superior results.

Adult↗
PubMed1992

Peritoneal clearances of carbon dioxide in the rat.

In our previous rat studies (Kidney Int. 1991; 39: 608-617) we evaluated peritoneal clearances (Cp) representing near exclusively diffusive CO2 transfer: for isosmotic (0.37% dextrose) and hyperosmotic (15% dextrose) solutions with pH 7.2-7.3, CpCO2 were 1.20 +/- 0.08 and 1.84 +/- 0.04 ml/min, respectively. In the present studies we have compared Cp of CO2 gas and HCO3- in anesthetized rats (n = 22) using solutions with dextrose contents as mentioned above but with pH 6.5 or 7.6; we have also evaluated how much Cp CO2 measurements obtained with solutions at these pH values differ from Cp shown earlier with the solutions of pH 7.2-7.3. Cp of CO2 gas and HCO3- were significantly higher under hyperosmotic than isosmotic conditions. The use of solutions of pH different from 7.2-7.3 resulted in higher Cp of CO2 gas: with isosmotic solutions of pH 6.5 and 7.6 mean increases were 25 and 75%, respectively; with hyperosmotic solutions respective increases were 45 and 134%. We conclude that dialysis solution osmolality and pH significantly change Cp of CO2 gas and HCO3- in the rat. For evaluation of peritoneal blood flow from diffusive transfer parameters of CO2 gas, smaller overestimation can be expected when dialysis solution pH is slightly under-than overadjusted compared to blood pH.

Animals↗
PubMed1992

Swan neck presternal ("bath tub") catheter for peritoneal dialysis.

We hypothesize that the swan neck catheter for peritoneal dialysis with exit in the presternal area will have better exit site healing and a decreased incidence of exit site infection than currently used peritoneal dialysis catheters with the exit located on the abdomen. The chest is a very stable structure, with minimal wall motion, especially of the upper chest and over the sternum. Hence, a catheter exit located on the chest will be subjected to only minimal movement. Decreased piston like movement of the catheter at the exit site reduces inward transfer of outer microbial flora. Moreover, a tight garment is usually not worn on the chest and there is less pressure on the exit. Based on this rationale a new catheter (swan neck presternal) has been designed. The presternal peritoneal dialysis catheter is composed of two flexible (silicon rubber) tubes joined through a titanium connector at the time of implantation. The device has been dubbed as a "bath tube" catheter because, with the exit on the chest, a patient may take a tub bath without the risk of exit contamination due to submersion. Two such catheters were implanted in two patients. One patient had multiple problems (including chronic exit site infection) with a previously implanted swan neck Missouri 2 catheter, the other patient was originally rejected as a peritoneal dialysis candidate due to extreme obesity. Both catheters healed well in 6 weeks and the exits have not become infected during the first 8 months. These preliminary experiences with 2 catheters support the rationale of their design.

Catheters, Indwelling↗
PubMed1992

What's new in peritoneal dialysis--an overview.

Patient survivals on continuous ambulatory peritoneal dialysis (CAPD) seem similar to survivals on hemodialysis (HD) in comparable populations. Technique survivals are improving on CAPD as peritonitis rates fall with the use of disconnect devices. Advances in catheter design and catheter care appear to be improving catheter survivals. The peritoneal membrane appears usable for many years provided that recurring peritonitis can be avoided. Mesothelial cell transplantation, low calcium solutions, and urea kinetic modeling are important new areas of interest with potentials to improve the therapy. Evidence continues to mount that residual renal function is better preserved in CAPD than in HD.

Cell Membrane Permeability↗
PubMed1992

Small solute clearances and clinical outcomes in CAPD.

The strong correlation of weekly clearances of urea and creatinine with PCR suggests that minimum targets of 50 L/week/1.73 m2 body surface area of creatinine clearance and a weekly kt/v urea of 1.7 are reasonable if protein intakes in excess of 0.8 g/kg normalized body weight are to be achieved in most CAPD patients. It would seem reasonable that this increases the chances for better nutrition. It would also seem reasonable that this should eventually improve long-term outcomes and survival in large population studies where the impact of dialysis dose could emerge as significant, even with the presence of all the other variables that are known to affect commonly monitored outcome parameters. These recommended targets are well below those achieved by hemodialysis; higher targets could possibly achieve even better long-term results, but this is unknown.

Creatinine↗
PubMed1992

Six-year experience with swan neck catheters.

From the beginning of our continuous ambulatory peritoneal dialysis (CAPD) program in January 1977 until June 1985, we used Tenckhoff and Toronto Western Hospital catheters. Throughout these years catheter survival probabilities of about 30% at three years persisted unchanged and were similar to survival probabilities reported by the National CAPD Registry special survey for these catheters. The first improvement in catheter results regarding leaks was noted after the adoption of lateral catheter insertion. Malfunction was less using swan neck prototypes from August 1985 to April 1986. The latter catheters were made of 80 degrees arc angle tubing between 8.5 cm spaced cuffs and were inserted in a reversed U-shape tunnel with the incision at the top of the tunnel. The use of these catheters was abandoned because of high cuff extrusion and exit infection rates. The next generation of swan neck catheters, the swan neck Missouri 2 and 3 catheters with straight intraperitoneal segments, improved the results dramatically. These catheters were made of 180 degrees arc angle tubing between 5 or 3 cm spaced cuffs. The estimated survival probability of 61% at three years more than doubled compared to previously used catheters. Recently we modified the intraperitoneal segment of the catheters, replacing the straight segment with a coiled one. These modified catheters, the swan neck Missouri coiled catheters, have been used exclusively since February 1990. In addition to an acceptable survival probability of 88% at one year, there are two major advantages of these catheters, the same as for other coiled catheters: elimination of infusion pain due to a jet effect and pain related to straight catheter tip pressure on the peritoneum experienced by some patients.

Bacterial Infections↗
PubMed1992

Weekly clearances of urea and creatinine on CAPD and NIPD.

Weekly creatinine clearance (Ccr) and weekly Curea/v (kt/v) are popular indices for quantitating the amount of peritoneal dialysis provided. Studies were undertaken on 44 patients on continuous ambulatory peritoneal dialysis (CAPD) and 10 patients on nightly intermittent peritoneal dialysis (NIPD) to compare relationships of weekly creatinine clearance to weekly urea clearance (Curea) divided by total body water (v). With a long cycle therapy such as CAPD, the ratio of weekly Ccr to weekly kt/v is higher than with a short cycle technique, such as NIPD, in the same patient. If patients are shifted from CAPD to NIPD maintaining the same weekly kt/v, the weekly Ccr will decrease. If patients are shifted from CAPD to NIPD maintaining the same weekly Ccr, then the weekly kt/v will increase. The clinical implications of these observations are unknown, but should be kept in mind for future studies comparing CAPD and NIPD.

Body Surface Area↗
PubMed1992

Recovery of renal function in continuous ambulatory peritoneal dialysis: a study of National CAPD Registry data.

From January 1981 to July 1988, the U.S. National CAPD Registry followed 23,771 patients on CAPD or CCPD for 3 months or more in 498 participating centers. Of these patients, 281 were deemed to have enough recovery of renal function to do without dialysis for at least 3 months. The median time on PD before recovery was 126 days in 138 patients treated only by PD from the start of dialysis. The median time to recovery in 106 patients was 238 days from the start of any chronic dialysis. A Cox model analysis revealed significantly (p less than 0.05) increased chances for renal function recovery in patients with systemic immunological diseases with renal involvement (relative risk for recovery [rr] = 2.48), patients with renal infarction related to renal vascular occlusion (rr = 4.13), and patients greater than 60 years of age compared to a younger group (rr = 1.72). However, patients greater than 60 and less than 21 experienced similar recovery rates. Reduced chances (p less than 0.05) for recovery were associated with diabetic glomerulosclerosis (rr = 0.25) and polycystic kidney disease (rr = 0.13). These findings show that renal function recovery rates in chronic hemodialysis and chronic peritoneal dialysis cannot be properly compared unless all risk factors (favoring or against recovery) are balanced, as in a prospective randomized trial.

Adult↗
PubMed1991

Ultrafiltration and effective peritoneal blood flow during peritoneal dialysis in the rat.

The dependence between maximum net ultrafiltration rate (nUFR) created by 15% dextrose dialysis solution and effective peritoneal capillary blood flow (EPBF) estimated by the diffusive mass transport coefficient (KBD) and peritoneal clearance (Cp) of CO2 gas was evaluated during 30 minute, 15 ml peritoneal dialysis exchanges in anesthetized rats (N = 18). The values of KBD for CO2 suggested a mean EPBF of 1.9 +/- 0.1 (SEM) ml/min for isosmotic exchanges and 2.7 +/- 0.2 ml/min for hyperosmotic ones with a mean maximum nUFR of 0.43 +/- 0.01 ml/min. Cp of CO2 measured after the first five minutes of dwell underestimated EPBF. In normally hydrated rats, maximum nUFR was achieved when the peritoneal filtration fraction was 32 +/- 2%. This value is similar to the glomerular filtration fraction in rats of 30%. Thus, our results indicate the following relationships: EPBF = (approximately 3 x maximum nUFR)/(1 - hematocrit). EPBF was about six times greater than maximum nUFR and exceeded about 57 times nUFR obtained under isosmotic conditions. These differences between EPBF and nUFR suggest normal EPBF is not a major limiting factor for maximum ultrafiltration achieved during peritoneal dialysis.

Animals↗
PubMed1991

Effect of hemodialysis on left ventricular systolic function in the presence and absence of beta-blockade: influence of left ventricular mass.

To assess the effect of hemodialysis on the left ventricular (LV) systolic function in the presence and absence of beta blockade, we performed echocardiography just prior to and immediately after 4-hour maintenance hemodialysis in 38 patients with end-stage renal disease. The LV systolic function was assessed in subgroups with normal and increased LV mass in both the beta blockade group (n = 19) and the non-beta blockade group (n = 19). There was a significant negative correlation between LV mass and the dialysis-induced change in the mean velocity of LV circumferential fiber shortening (mean Vcf) in both the beta blockade group (r = -0.93; p less than 0.0005) and in the non-beta blockade group (r = -0.82; p less than 0.0005). The mean dialysis-induced change in mean Vcf in the subgroup with increased LV mass in the beta blockade group (-0.02 +/- 0.11 circumferences/s) was significantly lower than the mean dialysis-induced change in mean Vcf in the non-beta blockade group (+0.12 +/- 0.04 circumferences/s; p less than 0.0005). Thus, the coexistence of increased LV mass and beta blockade significantly impedes the expected improvement of LV systolic function associated with hemodialysis.

Adrenergic beta-Antagonists↗
PubMed1991

Sieving and reflection coefficients for sodium salts and glucose during peritoneal dialysis in rats.

The two-part studies reported herein address peritoneal membrane ultrafiltrate (UF) characteristics during peritoneal dialysis exchanges in rats. In the studies of part 1, the sieving coefficients for sodium, chloride, and total solutes during hydrostatic UF after instillation of rat serum into the peritoneal cavity of rats were calculated. Thirty-six rats were divided into six groups (N = 6) according to the following peritoneal dialysis exchange cycle times: 60, 120, 180, 240, 480, and 960 min. Thirty milliliters of pooled rat serum were infused i.p. with the animal being conscious except during infusion and drainage. The study showed in the early phase of exchanges, when oncotic and osmotic pressure gradients were absent, net UF presumably due to capillary hydrostatic pressure and sodium sieving during such UF. Sieving coefficients for sodium (0.72), chloride (0.77) and total solutes (0.73) were determined by using standard formulae. In the second part of these studies, the kinetics of fluid movement after the instillation of 5% dextrose solution into the peritoneal cavity of rats were analyzed. A very low UF rate was observed early in the exchange when the glucose gradient between the dialysis solution and blood was at its peak. The UF rate gradually increased as the sodium entered the dialysis solution from the blood. At the time of low UF rate with high glucose gradient, presumably the osmotic pressure generated by the glucose in the dialysis solution was countered by the osmotic pressure of solutes in plasma, i.e., sodium and its anions.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1991

Morphology of peritoneal dialysis catheter tunnel: macroscopy and light microscopy.

There is scanty knowledge of the morphology of peritoneal dialysis catheter tunnels in humans, even though such knowledge may impact on peritoneal catheter design, implantation and postimplantation care. Past descriptions of catheter tunnels are based mainly on data from animal experiments. Based on these data, it has been assumed that epidermal spreading is inhibited by collagen fibers ingrown into the cuff. Our preliminary investigation indicated that this may not be the case in humans and led us to study catheter tunnel morphology in more detail. Eighteen catheter tunnels (2-5mm of tissue around the catheters) were removed in 17 peritoneal dialysis patients. The catheters were inserted 30 to 2013 days prior to removal (median 366 days). The catheters were removed electively or because of infectious or noninfectious complications. Contrary to the observations in animals, in only 1 case did epithelium extend to the cuff with only a minimal amount of granulation tissue present at the end of a 9 mm long sinus tract. In the remaining cases, the leading edge of the epithelium always met granulation tissue 1-14 mm from the exit, and the cuffs were found 8-33 mm from the exit. In tunnels older than 197 days, dense fibrous tissue was ingrown into the cuffs, and a dense fibrous capsule surrounded the cuff. The uninfected intercuff segment formed a pseudosheath, indistinguishable from a tendon sheath or synovial membrane. Infection in the catheter tunnel propagates through the part of the cuff adjacent to the tubing inside the capsule, suggesting that the cuff per se does not constitute a major barrier for spreading infection. This observation, by exclusion, infers that the beneficial role of an external cuff in decreasing exit infections is by providing firm anchorage of the catheter resulting in restriction of its piston like movement and thereby minimizing trauma and inward conveyance of outer sinus tract flora.

Adolescent↗
PubMed1990

Plasma and dialysate immunoglobulin G in continuous ambulatory peritoneal dialysis patients: a multicenter study.

Peritoneal dialysate immunoglobulin (Ig)G concentrations were measured in 120 continuous ambulatory peritoneal dialysis (CAPD) patients evaluated at four dialysis centers in different countries to assess the normal range for dialysate IgG and to investigate the relationships of this protein levels with peritoneal episodes, For 65 of these patients, plasma IgG levels were determined, and IgG clearances were calculated. The mean dialysate concentration of IgG was 6.9 +/- 4.2 mg/dl, and there was no difference between men and women or between patients who had or had not previously undergone hemodialysis. Dialysate IgG concentrations were significantly related to residual renal creatinine clearance and negatively correlated with dialysate volume, plasma albumin and total protein. There were no significant correlations between IgG levels in the dialysate and age, protein losses in the dialysate, time on CAPD or time from the last peritonitis episode. Plasma and dialysate IgG were unrelated to the incidence of peritonitis, statistical analysis being performed with different methods. These results suggest that IgG levels in the dialysate or plasma are not a major factor in the prevention of CAPD peritonitis.

Ascitic Fluid↗