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L N Newman

Publications and source records attributed to L N Newman.

11 recordsLinked to original sources
PubMed2001

Abdominal catastrophe: definition and proposal for a new approach.

Abdominal catastrophe, defined as peritonitis from a visceral source, occurs in a significant number of patients treated by peritoneal dialysis. Peritonitis due to visceral injury is difficult to manage and is associated with high morbidity and mortality. Surgical intervention for both diagnosis and repair is definitive. However, no preventive strategy has been identified to date. The experience at University Hospitals of Cleveland and the published experiences of many other centers demonstrate that the risk of this complication has not changed in parallel with the many other improvements in the technique and outcome of peritoneal dialysis. We propose an approach to improve the understanding and outcome of this devastating complication. First, classification of peritonitis by source, not by organism, may lead to a more focused response to each episode of peritonitis. Second, the importance of antibiotic prophylaxis should be re-assessed in defined clinical settings that have a high likelihood of progressing to abdominal catastrophe. Third, optimal antibiotic regimens need to be devised and applied when visceral injury is highly suspected as a cause of peritonitis. Finally, the results of surgical interventions must be carefully studied.

Humans↗
PubMed2000

The law of unintended consequences in action: increase in incidence of hypokalemia with improved adequacy of dialysis.

In 1996, we raised our peritoneal dialysis (PD) dose to meet new DOQI adequacy targets. Concurrently, we noted an increase in the frequency of K+ levels below 3.5 mEq/L. A continuous quality improvement (CQI) project was initiated to quantify the impact of increasing dialysis dose on the prevalence of hypokalemia in our unit. Measurements of serum K+, blood urea nitrogen (BUN), creatinine, residual renal function, and the number and type of clinical interventions required to maintain eukalemia were abstracted from the charts of 62 patients enrolled in our program for more than 6 months and having more than two adequacy data points. In the seven consecutive 6-month periods from January 1996 to June 1999, dialysis dose progressively increased while median serum K+ decreased, and the percentage of patients requiring either diet counselling or K+ supplementation rose from 9% to 42%. We conclude that the increased clearance of K+ that occurs with increasing dialysis dose may lead to significant hypokalemia in a large proportion of PD patients dialyzed to DOQI adequacy targets. Maintenance of eukalemia in this population often requires increased K+ intake and or oral supplementation. Further studies are needed to ascertain whether the prevalence of hypokalemia is sufficient to warrant routine addition of K+ to PD dialysis solutions.

Creatinine↗
PubMed1997

Oral pulsed calcitriol protocol reduces the prevalence of hyperparathyroidism in a PD unit.

A quality assessment (QA) activity revealed that the percentage of parathyroid hormone (PTH) levels above 300 micrograms/dL was higher in the peritoneal dialysis (PD) unit than in the hemodialysis (HD) unit (44% vs 27%). To reduce the proportion of patients with a target PTH above 200 micrograms/dL, a protocol that emphasized control of the serum phosphate level, standard pulsed doses of calcitriol, and increased patient education was created for the management of renal osteodystrophy. Serum calcium, phosphate, and PTH levels were obtained according to the protocol from July 1994 through June 1996. The percentage of patients achieving a PTH level below 200 micrograms/dL increased from 40% in June 1994 to 57% in June 1996. Significant differences were found in PTH levels at baseline and at test times 1, 2, and 3. Hypercalcemia (Ca > 12) occurred in 4% of the 532 Ca levels drawn during the study period and were due to breaches of protocol. In conclusion, we have confirmed previous work indicating that pulsed calcitriol can control elevated PTH levels in PD patients. Furthermore, we have developed a protocol that can be used as a QA tool to reduce the prevalence of hyperparathyroidism in the outpatient PD setting without inducing excess hypercalcemia.

Administration, Oral↗
PubMed1995

Variability in calculations of dialysis adequacy in patients using nightly intermittent peritoneal dialysis compared to CAPD.

Increasing numbers of patients receive peritoneal dialysis using noncontinuous methods such as nightly intermittent peritoneal dialysis (NIPD) rather than continuous ambulatory peritoneal dialysis (CAPD). We hypothesized that blood solute levels before and after NIPD would be large enough to produce significant variability in formulas based on the continuous peritoneal dialysis (PD) model. We found no diurnal differences in serum creatinine in NIPD or CAPD. However, our data demonstrate a 7.9% difference in serum urea measurements from evening to morning in patients treated by NIPD. This mathematical difference contributes to a 6.3% difference in the calculated value of KT/V and a 9.4% difference in the calculation of total urea clearance (liters per week) in these patients. By contrast, no difference in serum values or in calculated values of adequacy could be shown in patients on CAPD. These observations support the premise that CAPD represents a steady-state condition. NIPD patients demonstrate variability in serum levels of urea which may result in inaccurate calculations of dialysis adequacy. When blood samples are obtained in the morning soon after completing a cycle of NIPD, dialysis adequacy as measured by KT/V or total urea clearance (but not by total creatinine clearance) may be systematically overestimated.

Adult↗
PubMed1994

Cost-effective automated peritoneal dialysis for patients with average to low transport.

Patients with average to low transport kinetics are generally best dialyzed by standard continuous ambulatory peritoneal dialysis (CAPD) regimens that optimize clearance through longer dwell times. However, patients often request or require automated peritoneal dialysis (APD, also called cycler dialysis) in response to lifestyle issues. Our experience shows that these patients can be economically dialyzed in an 8 to 10 L mixed APD/CAPD regimen reversing the timing of traditional CAPD exchanges. The cost of a 9 L/day mixed regimen is comparable to that of 8 L/day CAPD.

Cost-Benefit Analysis↗
PubMed1993

A retrospective view of factors that affect catheter healing: four years of experience.

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.

Adolescent↗
PubMedDate not supplied

Abdominal catastrophe: visceral injury as a cause of peritonitis in patients treated by peritoneal dialysis.

OBJECTIVE: Peritonitis is considered an acceptable and controllable risk in patients undergoing chronic peritoneal dialysis (PD). In contrast, peritonitis due to visceral leakage represents a true "abdominal catastrophe" because of striking morbidity and mortality. To delineate the incidence, causes, and outcomes of catastrophic peritonitis, we compared patients who developed peritonitis due to documented visceral leakage with patients who developed peritonitis due to enteric organisms without evidence of visceral leakage. DESIGN: Retrospective chart review. SETTING: PD Unit located in tertiary care referral center. PATIENTS: 230 patients treated by PD between January 1988 and June 1996. MAIN OUTCOME MEASURES: All episodes of PD-related peritonitis occurring over an 8-year period. Hospital course of all patients with or without renal failure who were treated at University Hospitals of Cleveland for ischemic bowel disease, cholecystitis, viscus perforation, or diverticulitis. RESULTS: Anatomically documented visceral injury caused 32.5% of episodes of enteric bacterial peritonitis in 72 patients between January 1988 and June 1996. The overall incidence of this "abdominal catastrophe" was 11.3%, or 26 of a total of 230 patients treated by PD. Of the 26 patients, 50% died, 30.7% survived but switched permanently to hemodialysis, and only 19.2% remained on, or returned to, PD. Compared to renal failure patients treated by hemodialysis or transplantation and to non-renal failure patients, the incidence of abdominal catastrophe was 20-60 times greater in patients treated by PD. CONCLUSIONS: Evidence for injury of an abdominal organ should be sought in all patients treated by PD who develop peritonitis with enteric organisms. Surgical intervention is definitive for diagnosis, and if performed early may reduce morbidity and mortality.

Adult↗