OBJECTIVE:The purpose of this study (the third in a series of similar studies) is to evaluate the prevalence of Staphylococcus aureus (SA), methicillin-resistant SA (MRSA) and mupirocin-resistant SA (MuRSA) carriers in a peritoneal dialysis centre where patients have been instructed to use prophylactic mupirocin ointment at the catheter exit site over the last 7 years.METHODS:Swabs were taken from catheter exit site, nares, axillae and groin in 147 chronic peritoneal dialysis out-patients between November 2003 and January 2004. Axillae/groin and nasal samples were pooled and cultured in the same medium, whereas exit site swabs were cultured separately. All SA isolated were tested for methicillin and mupirocin resistance using oxacillin screening plates and E-test strips.RESULTS:Sixteen of 147 patients (10.9%) were found to be SA carriers: of these 13 (8.8%) had a positive nasal/axillae/groin culture; two (1.4%) had both nasal/axillae/groin- and exit site-positive culture; and one (0.7%) had only exit site-positive culture. In these 16 SA carriers, we found mupirocin-resistant strains (MuRSA) in four patients (25%) and MRSA in two patients (12.5%). Among the four MuRSA carriers, one had both nasal/axillae/groin- and exit site-positive culture and three had only nasal/axillae/groin-positive culture. Three high-level resistance and one low-level resistance MuRSA carriers were isolated. One MuRSA strain was also methicillin resistant. All MRSA strains were sensitive to vancomycin and rifampicin.CONCLUSION:After 7 years' routine use of prophylactic mupirocin ointment at the catheter exit site in non-selected chronic peritoneal dialysis patients, MuRSA was found in 25% of SA strains isolated or in 2.7% of the patients. Compared with our previous study, 3 years earlier, there is no significant increase in the MuRSA prevalence in peritoneal dialysis patients who routinely apply mupirocin ointment at the catheter exit site.

Renal cell carcinoma is a rare but seriouscomplication in ESRD patients. In thesepatients the incidence of renal cell carcinoma(RCC) is 20–40 times higher than in thegeneral population. We performed aretrospective study to measure the incidencerate, prevalence, characteristics and survivalamong our peritoneal dialysis (PD) patientsdiagnosed with renal cell carcinoma.The study was carried out among 607 patientswho were on the PD program from January 1997 toJune 2002. RCC was detected in eight patients(four males and four females) with mean age of52.1 ± 10.6 years. Among these eight patientsfour were new cases that were diagnosed beforethe patients were started on dialysis (three innative kidneys and one in a transplantedkidney). In the other four patients the RCC wasdiagnosed after they had been on dialysis for33–204 months (mean 60.75 ± 50.48). Wefound an incidence rate of 1.3 per 1000patients per year and a prevalence of 1.3%.Six of the eight patients had renal cysts.Tumor size was less than 7 cm in seven patientsand in the other patient it was 8.5 cm. Sevenof eight patients were alive at the time ofstudy with a survival time ranging from 3–138months (mean 122.25 ± 88.2) months. In onepatient, the RCC metastasised to the scalp,and, in two other patients, the tumorssubsequently involved the second kidney. Acardiovascular complication was the cause ofone death. Two patients received a renaltransplant 36 and 66 months after diagnosis.We conclude that despite the low rate ofmetastases and mortality in our study, regularultrasonography should be added to the followup of PD patients. Renal transplantation can beconsidered in these ESRD patients with RCC;however, close follow up for metastases isrecommended.

← Background A multidisciplinary approach has been shown to be of benefit in the prevention of lower limb ulceration and amputation in patients with diabetes, but there is less information on the role of such an approach in patients receiving dialysis treatment. ← Objective The purpose of the present study was to determine whether the institution of a chiropody program would result in fewer amputations in diabetic patients on peritoneal dialysis (PD). ← Design Retrospective chart review. ← Setting The PD program at a tertiary-care hospital. ← Patients Patients with diabetes that were enrolled in the PD program between January 1997 and December 1999, inclusive, that were offered the opportunity to see a chiropodist, and that agreed to be seen. A total of 132 patients were included. ← Intervention Education about foot care, assessment, and, in some instances, treatment by a chiropodist. ← Results Patients with an amputation were more likely to be male ( p < 0.01) and have peripheral vascular disease ( p < 0.001) compared to those without an amputation. They also had a lower average mean arterial pressure ( p < 0.05), lower weekly creatinine clearance ( p < 0.01), higher mean erythropoietin dose ( p < 0.05), and longer duration of end-stage renal disease ( p < 0.001). Factors that were predictive of shorter time to death or amputation were older age [hazard ratio (HR) = 1.03, p < 0.05], peripheral vascular disease (HR = 2.66, p < 0.01), and cerebrovascular disease (HR = 2.70, p < 0.01). Being seen by a chiropodist was protective (HR = 0.39, p < 0.01). ← Conclusion The current study suggests that a chiropody program may help to prevent amputation in patients with diabetes on PD.

Structural damage to polyurethane PD (peritoneal dialysis) catheters in patients using mupirocin ointment is widely appreciated, but damage to silicon rubber PD catheters is less well described. Ten catheters (6.6%) out of 152 were found to have structural alterations such as opacification, ballooning, thinning, and rupture. The duration of PD in these 10 patients ranged from 23 months to 80 months (mean duration 51.1 months). The frequency of mupirocin application varied from daily (2 cases) to 2–3 times per week (7 cases). In eight catheters opacification occurred at the exit site whereas one catheter showed opacification midway between the exit site and the titanium adaptor. One catheter showed opacification, ballooning, and thinning at the exit site ruptured in the form of two slit-like openings. In conclusion, various structural changes such as opacification, ballooning or thinning were seen in 6.6% of silicon rubber PD catheters in patients using mupirocin at the exit site. Although the mechanism remains elusive, mupirocin or the antiseptic solution alone or in combination may be contributory. We believe that this is an under-reported complication and encourage other health care givers to incorportate a search for such changes during clinic visits.

♦ Objective During the past few decades, the pattern of bone disease in uremic patients has changed significantly. There has been an increase in the number of patients with normal or low initial parathyroid hormone (PTH) levels, particularly in patients on chronic peritoneal dialysis (CPD). Previous authors have described a higher prevalence of bone pain, microfractures, and fractures, and higher mortality among these patients. The aim of this study was to determine the incidence, morbidity, and mortality of patients who had a low or normal intact PTH (iPTH) level when they started CPD. ♦ Design We reviewed the records of 251 patients in our program that started CPD during the past 5 years (January 1996 – December 2000). Clinical data, laboratory variables, medication, and dialysis parameters/dose were available at every clinic visit (approximately every 4 weeks). Intact PTH was used to express parathyroid function; values 3 times higher than the upper limit of normal (ULN) were assumed to be optimal. Variables predictive of the development of parathyroid dysfunction were calculated by univariate and multivariate logistic regression analysis. ♦ Results Of the patients who started CPD, 15.5% had iPTH values below the ULN (7.6 pmol/L), and an additional 29.5% had an iPTH of less than 3 times the ULN ( i.e., between 7.6 and 22.8 pmol/L). We call these two groups of patients the normal/low initial iPTH group. During the follow-up period (3 – 63 months), we found a trend toward increasing iPTH levels. By the end of the study period, 61.2% of those with normal/low initial iPTH remained in the normal/low iPTH range, and 38.8% had converted to a group with an iPTH range higher than 22.8 pmol/L. The patients who converted their iPTH grouping were younger, fewer of them were diabetics ( p = not significant), and they were more frequently on low calcium dialysate ( p < 0.05). Hyperphosphatemia was an independent risk factor for subsequent iPTH changes during the course of continuous ambulatory PD treatment. All patients in the normal/low iPTH groups had a low prevalence of bone fractures (3.5%). Also, patients who remained in the normal/low iPTH group at the end of the follow-up period did not have more fractures than those who converted to the hyperparathyroid group (3.8% vs 3.1%). We found no differences in bone fractures between patients with iPTH levels below 22.8 and those with levels above 22.8 pmol/L (3.5% vs 5.4%), nor were there differences in patient and technique survival between these two groups. ♦ Conclusion Normal/low initial iPTH is a frequent finding among patients starting CPD. Serum phosphorus was an independent risk factor for subsequent iPTH changes during the course of CPD treatment. Use of low calcium dialysate was significantly higher in patients who converted their iPTH into the high iPTH range. Very few patients with low/normal iPTH had bone-related symptoms (pain and fractures), and their morbidity and mortality did not differ from those patients with a high initial iPTH level.

Access to dialysis is the most infection prone part of any dialysis system. The prophylactic management of the exit site, the various access systems and their role in infections is discussed. Methods are suggested to avoid or control infections.

The authors carried out a retrospective chart review in 114 patients treated for at least two years at the Toronto Western Hospital Peritoneal Dialysis Unit and identified eight, who gained an "excessive" amount of weight equal to or greater than 10 kg of their initial weight. These patients had gained an average of 13.1 kg over the preceding two years. They are mostly males and their average age is 51 years. They are well-nourished normotenseive nondiabetics with mostly normal cardiac function. They are adequately dialyzed (per KT/V urea), have little residual renal function and typically have peritoneal membranes characterized by high average transport. According to BIA analysis, this weight gain was likely due to an increase in fat mass accompanied by a trend toward decreasing body-cell mass. This weight gain may be due to increased caloric intake secondary to dialysate glucose absorption in the setting of high average (peritoneal membrane) transport. Such excessive weight gain also may occur if these patients have polymorphism of the UCP-2 gene, which can alter metabolic rate.

Objective To compare efficacy in anemia correction and side effects of large doses of intravenous (IV) iron dextran and iron saccharate preparations in peritoneal dialysis (PD) patients. Setting Tertiary-care teaching hospital of University of Toronto. Design Retrospective analysis of 379 PD patients who attended PD clinics in past 5 years. Of these 379 patients, 62 were selected to receive IV iron based on ferrokinetic markers of iron deficiency, noncompliance to or ineffectiveness of oral iron, or increased erythropoietin (EPO) requirement. Intervention Sixty-one patients received two IV iron injections of 500 mg each, 1 week apart, 33 patients received iron dextran, 23 received iron saccharate, and 5 received both iron dextran and iron saccharate. One patient developed anaphylaxis to a test dose of iron dextran and was excluded from further therapy. Blood samples were collected before and 3 and 6 months after iron infusions. Results At 3 months, the group's average hemoglobin rose from 98.3 ± 18.3 g/L to 110.6 ± 16.4 g/L (p < 0.0001). Ferritin rose from 104.9 ± 115.4 μg/L to 391.5 ± 294.1 μg / L (p < 0.0001), and iron saturation from 0.17 ± 0.07 to 0.26 ± 0.19 (p < 0.0001). Erythropoietin requirements fell from 7278.7 IU/week to 5900 IU/week (p < 0.01). Five of the 34 patients who received iron dextran developed minor side effects and 1 patient had anaphylaxis to the test dose. Of the 23 patients who received iron saccharate, 1 had an anaphylactic reaction and 2 had transient chest pain, which subsided without therapy. Overall, there were more side effects with iron dextran (7.4% of injections) compared to the iron saccharate group (4.3% of injections), but this difference was statistically insignificant. Although statistically insignificant, there was an increase in the number of peritonitis episodes during the 6 months after IV iron infusion, especially with iron dextran, compared to the peritonitis episodes during the 6 months before iron infusions. Conclusion Our study indicates that IV iron in PD patients is effective in restoring iron stores and in decreasing EPO requirements. One anaphylactic reaction occurred in each group. Our data suggest that as much caution be exercised with iron saccharate as with iron dextran. The slight trend toward increased peritonitis rates after iron infusions needs to be investigated in a larger group of patients.

Related Articles, pp.1000, 1009, and 1014IN 25 YEARS OF wide use and acceptance as a form of management for end-stage renal disease, peritoneal dialysis (PD) has struggled with three major problems: reimbursement, adequacy of dialysis, and frequent episodes of peritonitis. From the beginning, this form of dialysis was expensive and did not always provide adequate treatment, especially in large patients.The first problem—reimbursement—was solved in time, and units choosing this form of dialysis for some of their patients are now receiving adequate financial support. Although we understand the second problem—adequacy of dialysis—better today, the problem is still with us.1National Kidney Foundation NKF-DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy.Am J Kidney Dis. 1997; 30: S67-S136Google Scholar Nevertheless, the recognition that some patients on peritoneal dialysis preserve their residual renal function longer than those on hemodialysis has been a strong argument for considering PD as the initial form of dialysis.2Venkataraman V Nolph KD Preservation of residual renal function—An important goal.Perit Dial Int. 2000; 20: 302-305Google ScholarFrom the inception of this treatment, peritonitis has been the greatest concern. It was not unusual for a PD patient to suffer 4 or 5 peritonitis episodes a year, leading to patient suffering, cost, and transfer to hemodialysis. This created a strong resistance among nephrologists as well as patients to this form of dialysis. This resistance was so strong that in 1982 The Lancet went so far as to call PD “Ambulatory Peritonitis.”3Anonymous Lancet. 1982; 1 (editorial): 1104-1105Google ScholarMajor changes came about when Oreopoulos et al4Oreopoulos DG Robson M Izatt S Clayton S de Veber GA A simple and safe technique for continuous ambulatory peritoneal dialysis (CAPD).Trans Am Soc Artif Intern Organs. 1978; 24: 484-489Google Scholar introduced dialysis fluid delivered from plastic bags. This reduced the rate of peritonitis, and the method became suitable for home treatment. Further improvements followed. New connection technology was developed; peritoneal catheter designs were changed, and the method of surgical implantation was modified. Simultaneously, the therapy of dialysis-related peritonitis changed.5Vas SI Keane WF Treatment of peritonitis: Update or new course.Perit Dial Int. 2000; 20: 384-385Google Scholar The rate of peritonitis fell to about one episode every 2 years, and some units report even better results.As the technology improved and rate of infection fell, the causative organisms changed. Fewer infections originated in the delivery system. Thus, staph infections became less common, while gram-negative enteric organisms were more frequently isolated.6Zelenitsky S Barns L Findlay I Alfa M Ariano R Fine A Harding G Analysis of microbiological trends in peritoneal dialysis–related peritonitis from 1991 to 1998.Am J Kidney Dis. 2000; 36: 1009-1013Abstract Full Text Full Text PDF Scopus (158) Google Scholar When gram-positive infections were encountered, they were often resistant to methicillin and ciprofloxacin. Polymicrobial peritonitis became increasingly common.7Kim GC Korbet SM Polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients.Am J Kidney Dis. 2000; 36: 1000-1008Abstract Full Text Full Text PDF Scopus (47) Google ScholarWhile the origin of these polymicrobial infections is not certain, they probably arise from minute perforations of the intestine, perhaps through diverticula. Alternatively, organisms may pass through the bowel wall that is temporarily ischemic. Polymicrobial peritonitis is difficult to treat in the presence of a foreign body (catheter) and often requires removal of the dialysis catheter, which, in turn, may lead to permanent transfer of the patient to hemodialysis. The increased incidence of gram-negative infections necessitated increased use of aminoglycoside antibiotics with their attendant toxicity.5Vas SI Keane WF Treatment of peritonitis: Update or new course.Perit Dial Int. 2000; 20: 384-385Google ScholarThe rate of peritonitis secondary to early postoperative wound infection is not known. These infections commonly lead to later exit site infections. The use of preoperative antibiotics prophylaxis has been an open question. In this issue of the Journal , Gadallah et al8Gadallah MF Ramdeen G Mignone J Patel D Mitchell L Tatro S Role of preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters.Am J Kidney Dis. 2000; 36: 1014-1019Abstract Full Text Full Text PDF Scopus (111) Google Scholar show a significant reduction in postinsertion peritonitis in patients receiving preoperative antibiotic prophylaxis. In this study, the catheters were placed using peritoneoscopy. According to the US Renal Data System, 75% of catheters are placed by surgical dissection, but only 43% receive antibiotic prophylaxis.9US Renal Data System:Google Scholar Whether widespread use of prophylactic antibiotics will make a large dent in PD-associated peritonitis remains to be determined. The emergence of vancomycin-resistant organisms complicates the choice of the antibiotic used for prophylaxis.Other advances may further reduce PD-associated peritonitis. One of these advances is the introduction of biocompatible dialysis solutions. While we have known that the low pH and high osmolality of the previously used solutions interferes with phagocytosis and bacterial killing, no evidence is yet available that biocompatible solutions will decrease the incidence of peritonitis. In another new development, increased use of automated PD has lowered the rate of peritonitis.10Alflaiw AIW Vas S Oreopoulos DG Peritonitis in APD patients: Diagnosis and treatment.in: Contributions to Nephrology: Automated Peritoneal Dialysis. Karger AG, Basel, Switzerland1999: 213-228Google Scholar And if catheter tubing with better biocompatibility can be found, peritonitis rates may be further decreased. Although prophylactic treatment of the exit site with mupirocin ointment has been shown to reduce the incidence of Staphylococcus aureus peritonitis,11Thodis E Bhaskaran S Pasadakis P Bargman JM Vas SI Oreopoulos DG Decrease in Staphylococcus aureus exit-site infections and peritonitis in CAPD patients by local application of mupirocin ointment at the catheter exit site.Perit Dial Int. 1998; 18: 261-270Google Scholar prophylactic programs to reduce nasal carriers of S aureus have not proven useful. Despite the progress achieved in the last 25 years, a conclusive solution is still elusive and researchers are left with the task of searching for new ways to address an old problem. Related Articles, pp.1000, 1009, and 1014 IN 25 YEARS OF wide use and acceptance as a form of management for end-stage renal disease, peritoneal dialysis (PD) has struggled with three major problems: reimbursement, adequacy of dialysis, and frequent episodes of peritonitis. From the beginning, this form of dialysis was expensive and did not always provide adequate treatment, especially in large patients. The first problem—reimbursement—was solved in time, and units choosing this form of dialysis for some of their patients are now receiving adequate financial support. Although we understand the second problem—adequacy of dialysis—better today, the problem is still with us.1National Kidney Foundation NKF-DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy.Am J Kidney Dis. 1997; 30: S67-S136Google Scholar Nevertheless, the recognition that some patients on peritoneal dialysis preserve their residual renal function longer than those on hemodialysis has been a strong argument for considering PD as the initial form of dialysis.2Venkataraman V Nolph KD Preservation of residual renal function—An important goal.Perit Dial Int. 2000; 20: 302-305Google Scholar From the inception of this treatment, peritonitis has been the greatest concern. It was not unusual for a PD patient to suffer 4 or 5 peritonitis episodes a year, leading to patient suffering, cost, and transfer to hemodialysis. This created a strong resistance among nephrologists as well as patients to this form of dialysis. This resistance was so strong that in 1982 The Lancet went so far as to call PD “Ambulatory Peritonitis.”3Anonymous Lancet. 1982; 1 (editorial): 1104-1105Google Scholar Major changes came about when Oreopoulos et al4Oreopoulos DG Robson M Izatt S Clayton S de Veber GA A simple and safe technique for continuous ambulatory peritoneal dialysis (CAPD).Trans Am Soc Artif Intern Organs. 1978; 24: 484-489Google Scholar introduced dialysis fluid delivered from plastic bags. This reduced the rate of peritonitis, and the method became suitable for home treatment. Further improvements followed. New connection technology was developed; peritoneal catheter designs were changed, and the method of surgical implantation was modified. Simultaneously, the therapy of dialysis-related peritonitis changed.5Vas SI Keane WF Treatment of peritonitis: Update or new course.Perit Dial Int. 2000; 20: 384-385Google Scholar The rate of peritonitis fell to about one episode every 2 years, and some units report even better results. As the technology improved and rate of infection fell, the causative organisms changed. Fewer infections originated in the delivery system. Thus, staph infections became less common, while gram-negative enteric organisms were more frequently isolated.6Zelenitsky S Barns L Findlay I Alfa M Ariano R Fine A Harding G Analysis of microbiological trends in peritoneal dialysis–related peritonitis from 1991 to 1998.Am J Kidney Dis. 2000; 36: 1009-1013Abstract Full Text Full Text PDF Scopus (158) Google Scholar When gram-positive infections were encountered, they were often resistant to methicillin and ciprofloxacin. Polymicrobial peritonitis became increasingly common.7Kim GC Korbet SM Polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients.Am J Kidney Dis. 2000; 36: 1000-1008Abstract Full Text Full Text PDF Scopus (47) Google Scholar While the origin of these polymicrobial infections is not certain, they probably arise from minute perforations of the intestine, perhaps through diverticula. Alternatively, organisms may pass through the bowel wall that is temporarily ischemic. Polymicrobial peritonitis is difficult to treat in the presence of a foreign body (catheter) and often requires removal of the dialysis catheter, which, in turn, may lead to permanent transfer of the patient to hemodialysis. The increased incidence of gram-negative infections necessitated increased use of aminoglycoside antibiotics with their attendant toxicity.5Vas SI Keane WF Treatment of peritonitis: Update or new course.Perit Dial Int. 2000; 20: 384-385Google Scholar The rate of peritonitis secondary to early postoperative wound infection is not known. These infections commonly lead to later exit site infections. The use of preoperative antibiotics prophylaxis has been an open question. In this issue of the Journal , Gadallah et al8Gadallah MF Ramdeen G Mignone J Patel D Mitchell L Tatro S Role of preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters.Am J Kidney Dis. 2000; 36: 1014-1019Abstract Full Text Full Text PDF Scopus (111) Google Scholar show a significant reduction in postinsertion peritonitis in patients receiving preoperative antibiotic prophylaxis. In this study, the catheters were placed using peritoneoscopy. According to the US Renal Data System, 75% of catheters are placed by surgical dissection, but only 43% receive antibiotic prophylaxis.9US Renal Data System:Google Scholar Whether widespread use of prophylactic antibiotics will make a large dent in PD-associated peritonitis remains to be determined. The emergence of vancomycin-resistant organisms complicates the choice of the antibiotic used for prophylaxis. Other advances may further reduce PD-associated peritonitis. One of these advances is the introduction of biocompatible dialysis solutions. While we have known that the low pH and high osmolality of the previously used solutions interferes with phagocytosis and bacterial killing, no evidence is yet available that biocompatible solutions will decrease the incidence of peritonitis. In another new development, increased use of automated PD has lowered the rate of peritonitis.10Alflaiw AIW Vas S Oreopoulos DG Peritonitis in APD patients: Diagnosis and treatment.in: Contributions to Nephrology: Automated Peritoneal Dialysis. Karger AG, Basel, Switzerland1999: 213-228Google Scholar And if catheter tubing with better biocompatibility can be found, peritonitis rates may be further decreased. Although prophylactic treatment of the exit site with mupirocin ointment has been shown to reduce the incidence of Staphylococcus aureus peritonitis,11Thodis E Bhaskaran S Pasadakis P Bargman JM Vas SI Oreopoulos DG Decrease in Staphylococcus aureus exit-site infections and peritonitis in CAPD patients by local application of mupirocin ointment at the catheter exit site.Perit Dial Int. 1998; 18: 261-270Google Scholar prophylactic programs to reduce nasal carriers of S aureus have not proven useful. Despite the progress achieved in the last 25 years, a conclusive solution is still elusive and researchers are left with the task of searching for new ways to address an old problem.

Department of Medicine,1 Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis, Minnesota; Albany College of Pharmacy,2 Albany, New York, U.S.A.; Department of Peritoneal Dialysis,3 Academic Medical Center, Amsterdam, The Netherlands; Manchester Royal Infirmary,4 Manchester, United Kingdom; Vanderbilt University Medical Center,5 Nashville, Tennessee; Baxter Healthcare Corporation,6 McGaw Park, Illinois, U.S.A.; Renal Division,7 Jikei-kai University, School of Medicine, Tokyo, Japan; University of Pittsburgh Medical Center,8 Pittsburgh, Pennsylvania, U.S.A.; Renal Division,9 Department of Medicine, Evangelic School of Medicine, Curitiba Parana, Brazil; University of Toronto,10 Toronto Hospital, Toronto, Ontario, Canada

Objectives: Parathyroid dysfunction continues to produce significant morbidity in dialysis patients. Since the introduction of low calcium dialysate for peritoneal dialysis (PD), no large studies have been done to determine the prevalence of parathyroid dysfunction in these patients. This study was done to assess the prevalence of parathyroid disease in the PD population and to determine the risk factors associated with this dysfunction.Design: We analyzed data on 176 patients who received PD at a single center between August 1998 and February 1999. Clinical data, laboratory variables related to parathyroid function, and data pertaining to dialysis treatment and weekly drug dosing were obtained for each patient on two different occasions, approximately 3 months apart. Variables predictive of the development of parathyroid dysfunction were calculated by univariate and multivariate logistic regression analysis.Results: Two-thirds of the patients surveyed had an abnormal intact parathyroid hormone (iPTH) level: 47% had an iPTH level more than three times normal, the mean was 54.6 +/- 35.4 pmol/L; 23% had an iPTH value below the upper limit of normal, here the mean was 3.6 +/- 1.8 pmol/L. Diabetic patients had lower iPTH levels (22.2 +/- 28.4 pmol/L) than nondiabetics (33.9 +/- 34.8 pmol/L) (p = 0.02). On multivariate regression analysis, we found that age, duration of dialysis, Kt/V, serum bicarbonate, and serum ionized calcium levels did not significantly affect parathyroid function. Hyperphosphatemia was the only factor that was associated with the development of secondary hyperparathyroidism in this study population (p = 0.029).Conclusion: There is a high prevalence of hyperparathyroidism in the current PD population. Phosphate control is suboptimal and hyperphosphatemia is an independent risk factor for the development of hyperparathyroidism.

amikacin (0.2 mg/kg/day) was started as the first-line treatment of CAPD peritonitis, according to the recommendations of the third report of the Ad Hoc Advisory Committee on Peritonitis Management (2). The cure rate of the first 34 episodes treated with this protocol was 55.8% (19/34) and 59.3% (19/32), if fungus and Pseudomonas spp were excluded. The identified micro-organisms were Staphylococcus aureus (26.5%, 9/34), S. epidermidis (14.7%, 5/34), Streptococcus sp (8.8%, 3/34), Enterococcus faecalis (5.9%, 2/34), Serratia marcescens (5.9%, 2/34), Klebsiella pneumoniae (5.9%, 2/34), Enterobacter sp (2.9%, 1/34), Pseudomonas aeruginosa (2.9%, 1/34), yeast forms (2.9%, 1/34), and negative culture (17.6%, 6/34). The therapeutic response was not statistically different among episodes caused by gram-positive species, gram-negative species, and those with negative culture. Concerning the sensitivity to antibiotics, 66.6% of episodes caused by S. aureus (6/9) and 20% of those caused by S. epidermidis (1/5) were sensitive to cefazolin. Thus, the low sensitivity observed in grampositive species may have contributed to the poor response verified in our series. The difference of cure rate between our patients and those of Lai et al. cannot be explained by variations of distribution of etiological agents, and possibly also not by the use of amikacin instead of gentamicin in our cases. The small number of cases in both series, or the possible variation in sensitivity of the micro-organisms among different centers, may explain the observed results. We think further studies are necessary to clarify the effectivity of associations of first-generation cephalosporins and aminoglycosides, proposed for the initial treatment of CAPD peritonitis.

There is evidence that high frequency, as well as long duration, hemodialysis provides better clinical outcomes. We developed nocturnal hemodialysis, a new innovative form of renal replacement therapy, which is performed six to seven nights per week for 8 to 10 h during sleep at home. Blood flow was set at 300 ml/min and dialysate flow at 100 ml/min. An internal jugular catheter was used as the vascular access. Special precautions were taken to prevent accidental disconnection during sleep, as well as air embolization. Dialysis functions from the patient's home were monitored continuously via a modem at the nocturnal hemodialysis center. Twelve patients have completed training and have been successfully performing nocturnal hemodialysis for up to 34 mo. This study represents 170 patient months of experience accumulated over 3 yr. There was hemodynamic stability and significant subjective improvement in patient well being. Nightly Kt/V was 0.99. Weekly removal of phosphate was twice as high and beta2 microglobulin 4 times as high as conventional hemodialysis. All patients have discontinued their phosphate binders and have increased dietary phosphate and protein intake. BP control was achieved with fewer medications. Dialyzer reuse has decreased the operating costs to the level of the other form of home dialysis. Complications were infrequent and were related primarily to the dialysis access. Nocturnal hemodialysis represents the most efficient form of dialysis at low cost and should be considered as an option for patients who can be trained for home hemodialysis.