RESUMEN
The presence of a biofilm within the peritoneal dialysis catheter where bacteria are encapsulated, protected from the action of antibiotics and insidiously liberated within the dialysate, best explains the relapse of the infectious peritonitis, when antibiotics are withdrawn. We here report a serie of four clinical cases in whom the administration of urokinase within the peritoneal catheter in addition to the current antibiotherapy, has cured relapsing peritonitis due to Staphylococcus epidermidis in two cases, Acinetobacterjohnsonii in one case and Staphylococcus haemolyticus in one case, respectively. This approach, safe and easy, allowed the infection eradication and did prevent a catheter removal and a potential transfer of the patients to hemodialysis.
Asunto(s)
Diálisis Peritoneal , Peritonitis , Antibacterianos , Catéteres de Permanencia/efectos adversos , Humanos , Peritonitis/tratamiento farmacológico , Recurrencia , Esterilización , Activador de Plasminógeno de Tipo UroquinasaRESUMEN
Outpatient hemodialysis therapy (HD) can be associated with hemodynamic compromise. Bioreactance has recently been shown to provide accurate, noninvasive, continuous, measurements of cardiac output (CO) and thoracic impedance (Zo) from which thoracic fluid content (TFC) can be derived assuming TFC=1000/Zo. This study was designed to evaluate the changes in TFC in comparison with the traditional indices of fluid removal (FR) and to understand the trends in CO changes in HD patients. Minute-by-minute changes in TFC and CO were prospectively collected using the bioreactance system (NICOM) in HD patients of a single unit. Changes in body weight (DeltaW), hematocrit (DeltaHct), and amount of FR were also measured. Twenty-five patients (age 77 +/- 11 years) were included. The TFC decreased in all patients by an average of 5.4 +/- 7.9 kohm(-1), weight decreased by 1.48 +/- 0.98 kg, and FR averaged 2.07 +/- 1.93 L over a 3- to 4-hour HD session. There were good correlations between DeltaTFC and DeltaW (R=0.80, P<0.0001) and FR (R=0.85, P<0.0001). DeltaHct (4.13 +/- 3.42%) was poorly correlated with DeltaTFC (R=0.35, P=0.12) and FR (R=0.40, P=0.07). The regression line between FR and TFC yielded FR=1.0024-0.1985TFC; thus, a 1 kohm(-1) change of Zo correlates with an approximately 200 mL change in total body water. The change in CO (-0.52 +/- 0.49 L/min m(2)) during HD did not correlate with FR (R=0.15, P=NS). Changes in TFC represented the monitored variable most closely related to FR. CO remained fairly constant in this stable patient cohort. Further studies in high-risk patients are warranted to understand whether TFC and CO monitoring can improve HD session management.
Asunto(s)
Gasto Cardíaco , Cardiografía de Impedancia/métodos , Fallo Renal Crónico/diagnóstico , Diálisis Renal , Tórax , Anciano , Líquidos Corporales , Femenino , Humanos , Fallo Renal Crónico/terapia , Masculino , Factores de TiempoRESUMEN
UNLABELLED: Renal dysfunction is a frequent and severe complication after conventional hypothermic cardiac surgery. Little is known about this complication when cardiopulmonary bypass (CPB) is performed under normothermic conditions (e.g., more than 36 degrees C). Thus, we prospectively studied 649 consecutive patients undergoing coronary artery bypass surgery or valve surgery with normothermic CPB. The association between renal dysfunction (defined as a > or =30% preoperative-to-maximum postoperative increase in serum creatinine level) and perioperative variables was studied by univariate and multivariate analysis. Renal dysfunction occurred in 17% of the patients. Twenty-one (3.2%) patients required dialysis. Independent preoperative predictors of this complication were: advanced age, ASA class >3, active infective endocarditis, radiocontrast agent administration <48 h before surgery, and combined surgery. When all the variables were entered, active infective endocarditis, radiocontrast agent administration, postoperative low cardiac output, and postoperative bleeding were independently associated with renal dysfunction. The in-hospital mortality rate was 27.5% when this complication occurred (versus 1.6%; P < 0.0001). Furthermore, postoperative renal dysfunction was independently associated with in-hospital mortality (odds ratio, 4.1 [95% confidence interval, 1.3-12.8]). We conclude that advanced age, active endocarditis, and recent (within 48 h) radiocontrast agent administration, as well as postoperative hemodynamic dysfunction, are more consistently predictive of postoperative renal dysfunction than CPB factors. IMPLICATIONS: We found that postoperative renal dysfunction was a frequent and severe complication after normothermic cardiac surgery, independently associated with poor outcome. Independent predictors of this complication were advanced age, active endocarditis, and recent (within 48 h) radiocontrast agent administration (the only preoperative modifiable factor), as well as postoperative hemodynamic dysfunction.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Puente Cardiopulmonar/efectos adversos , Enfermedades Renales/epidemiología , Enfermedades Renales/etiología , Anciano , Análisis de Varianza , Temperatura Corporal/fisiología , Estudios de Cohortes , Femenino , Humanos , Enfermedades Renales/terapia , Pruebas de Función Renal , Tiempo de Internación , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Resultado del Tratamiento , Vejiga Urinaria/fisiologíaRESUMEN
BACKGROUND: Dialysis is becoming increasingly frequent in patients over 75 years of age. Age is a superimposed comorbid factor commonly associated with poor prognosis in these patients. OBJECTIVE: To analyze the survival of 292 patients aged over 75 years on initiation of peritoneal dialysis (PD) from September 1982 to September 1999. DESIGN: Retrospective study. SETTING: Nephrology department in a University Hospital. RESULTS: Mean age was 81.5 years (range 75-92 years); 178 patients were over 80 years and 60 patients were over 85 years. Sex ratio was 136F/156M. Ninety-day mortality rate was 12%. Excluding the first 3 months, median patient survival was 21.6 months; 226 patients died on PD and 24 were shifted to hemodialysis. Survival was inversely correlated with the Charlson combined comorbidity index (CCI), but independent of predialysis hemoglobin and serum albumin levels. Over three selected periods, 1982-1989, 1989-1995, and 1995-1999, an increase was found in mean age (79.7 +/- 3.3, 82.6 +/- 3.9, and 81.8 +/- 4.4 years; p < 0.001), CCI (7.6 +/- 1.59, 8.0 +/- 1.52, and 8.5 +/- 1.63; p = 0.01), and predialysis creatinine clearance (6.2 +/- 2.3, 6.4 +/- 2.4, and 9.8 +/- 3.8 mL/minute; p < 0.001). Median survival was similar in the various selected periods (21.0, 21.5, and 25.4 months). The incidence of peritonitis decreased from 0.63 to 0.21 episodes per patient year. CONCLUSION: From 1982 to 1999, mean age and comorbidity increased on initiation of dialysis in elderly patients, with no increase in mortality. Survival in elderly patients on PD was related to the age-comorbidity index.