Biomedical subjects
Publications and source records attributed to K Nolph.
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Peritonitis following urticaria on two occasions in a 46-year-old white female treated with CAPD for nine years is reported. On both occasions an episode of urticaria and pruritus occurred 24 hr before the dialysate became cloudy, and the patient experienced abdominal pain, nausea, and vomiting. The culture of the peritoneal dialysis effluent grew gamma Streptococcus with the first episode. To our knowledge this is the first report of CAPD peritonitis preceded by urticaria where the skin findings were most likely related to the peritoneal infection.
In 1989, a conference was held to discuss the current status of technique survival for patients treated with continuous ambulatory peritoneal dialysis (CAPD). Major reasons for patient drop-out from CAPD-peritonitis, inadequate dialysis, catheter-related problems and psychosocial factors-were reviewed, as were constructive techniques for dealing with these problems and areas for future investigation.
Experiences with peritonitis in a continuous ambulatory peritoneal dialysis (CAPD) program at a single center over 8 years were reviewed. Home-acquired peritonitis rates have been less than 1 episode per patient year since 1982. Gram-positive organisms continue to account for most episodes in a similar proportion. Actual known contamination could be pinpointed in only 7.4% of cases, but was strongly suspected in 35.8% of episodes. Exit site and/or tunnel infections were thought to have caused 20% of the cases. Intrinsic peritonitis probably accounted for 10.5%. Recurrence of peritonitis with the same organisms following cessation of antibiotics represented only 2.1% of cases.
Few studies have explored how patient characteristics may influence clearances. We sought to determine if patient age, sex, size, renal disease, blood pressure, hematocrit, serum total proteins and albumin affected peritoneal clearances, drainage volumes or dialysate protein concentration. We found inulin clearances to be related to surface area and total serum proteins. Creatinine clearance was related to age, serum albumin and hematocrit. Sex, blood pressure or type of renal disease did not influence peritoneal clearances.
Continuous ambulatory peritoneal dialysis (CAPD) might result in peritoneal membrane changes. First, CAPD exposes essentially continuously the peritoneum to peritoneal dialysis solutions. Such solutions differ from the usual extracellular fluid bathing peritoneal tissues. Second, this technique may be complicated by an increased frequency of peritonitis when compared to intermittent peritoneal dialysis. We undertook a prospective study of patients undergoing CAPD to determine if there were decreases in peritoneal clearances and if the peritoneal microcirculation maintained its responsiveness to nitroprusside. Peritoneal transport, as assessed by the clearances of urea, creatinine, inulin, and dialysate protein concentration, with and without nitroprusside addition in the dialysis solution, is unchanged in patients undergoing CAPD for up to 1 year, despite frequent episodes of peritonitis.
Dextran sodium sulfate was evaluated in vitro as a potential non-absorbable osmotic agent for peritoneal dialysis. It was compared to poly(sodium acrylate) which has been shown previously to be effective in rats, but probably toxic. Dextran sodium sulfate induced osmotic ultrafiltration rates as high as 20 ml/min in water but only 2 ml/min in solution containing non-polymer electrolytes presumably because of Gibbs-Donnan effects. Compared to acrylate the dextran polymer has less sodium per gram, lower osmotic activity of polymer sodium, and yields less ultrafiltration at given transmembrane osmolalities. A non-toxic polymer more like acrylate would seem more promising as an osmotic agent for peritoneal dialysis.
It has been proposed that urea and creatinine may bind to red cell constituents. In the present studies, whole blood and plasma concentrations of urea and creatinine were compared using autoanalyzer techniques (that require solutes to pass through a dialysis membrane) and manual techniques (with no dialysis membrane). Blood samples from 11 normal and 10 azotemic subjects were studied. Concentration differences between plasma water and red cell water for these solutes were significant in normals with standard manual but not with autoanalyzer methods. Accordingly, red cell water concentrations in normals were greater with manual methods than with autoanalyzer methods. In azotemics, differences between red cell and plasma water concentrations and differences in red cell water concentrations between methods were proportionately less. The findings suggest that accumulation of these solutes in the red cell in azotemia is predominantly in the freely diffusable form. Any chemical interference of red cell proteins and/or solute binding to red cell constituents yields significant discrepancies between manual and autoanalyzer methods only at lower BUN and creatinine concentrations.
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A 25-year-old white man with gout and nephropathy and with a previous reaction to allopurinol was given a trial dose of oxypurinol. He developed malaise, a generalized erythematous reaction with edema, pruritus, and emesis; this was clinically identical to the reaction he experienced with allopurinol. When the patient's lymphocytes were exposed in vitro to oxypurinol and allopurinol, increased DNA synthesis was observed, suggesting an immunologic basis for the reaction. This patient indicates that clinical cross reactivity to allopurinol and oxypurinol does occur and may be of an immunologic basis. There is a need for additional xanthine oxidase inhibitors for such patients.
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