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Infectious complications are the leading cause of morbidity and mortality in peritoneal dialysis (PD) patients. Infectious diseases play a role in the morbidity and mortality of hemodialysis (HD) patients as well. Prevention of transmission of infectious diseases is of paramount importance in any program concentrating on renal replacement therapy, including HD, PD and kidney transplantation. Despite effective means to eradicate infections, increased usage of antimicrobial agents has resulted in antimicrobial resistance. The focus of this paper will be infections in dialysis. Some of the infectious complications discussed here may be applicable to patients with end-stage renal disease who have received a kidney transplant. Prevention of infections in dialysis includes development of infection control strategies by dialysis units with appropriate surveillance strategies. Dialysis staff education, patient education and physician participation is essential for successful infection control in dialysis units. Patients with other chronic infections, such as hepatitis B and human immunodeficiency virus (HIV) infection on dialysis may require additional infection control strategies for dialysis units to prevent infection of other patients and dialysis unit staff. Surveillance and prevention of tuberculosis is part of the comprehensive infection control plan for patients and staff and special considerations may occur for treatment of tuberculosis in other epidemiologic and economic areas of the world. Immunizations, a cornerstone to prevent many infections, have led to decreased morbidity and mortality for many diseases and many immunizations play a role in prevention of disease in dialysis patients.

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Minority physicians provide care in a manner that promotes patient satisfaction and meets the needs of an increasingly diverse U.S. population. In addition, minority medical school faculty bring diverse perspectives to research and teach cross-cultural care. However, men and women of color remain underrepresented among medical school faculty, particularly in the higher ranks. National data show that although the numbers of women in medicine have increased, minority representation remains essentially static. Studying minority women faculty as a group may help to improve our understanding of barriers to diversification. Six National Centers of Excellence in Women's Health used a variety of approaches in addressing the needs of this group. Recommendations for other academic institutions include development of key diversity indicators with national benchmarks, creation of guidelines for mentoring and faculty development programs, and support for career development opportunities.

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Exit-site infections (ESIs) are frequently due to gram-positive organisms and occasionally to gram-negative organisms. Initial empiric antibiotic therapy is therefore directed against these organisms until culture reports are available. Two cases of ESI associated with Mycobacterium are here reported. The first patient, a 63-year-old man with type 2 diabetes, recently treated for Staphylococcus epidermidis peritonitis, presented with acute purulent drainage at the catheter exit site, accompanied by pain and erythema. No tunnel abscess was identified by ultrasound. Empiric antibiotic therapy was initiated with ofloxacin and vancomycin. A rapid-growing acid-fast bacillus (AFB) noted four days after culture was eventually identified as Mycobacterium fortuitum. Ofloxacin was continued, vancomycin was discontinued, and clarithromycin was added. The ESI initially showed improvement; therapy was therefore continued for several months. However, cultures remained positive for M. fortuitum, and the catheter was removed 5 months after therapy was initiated. The second patient, a 28-year-old woman, presented with severe pain and tenderness at the exit site without erythema or drainage. Empiric therapy with cefazolin, gentamicin, and cephalexin was initiated. Gram-positive cocci and an AFB were identified from the exit-site culture, and antibiotics were initially changed to clarithromycin, trimethoprim/sulfamethoxazole, and ofloxacin. The organisms were subsequently identified as M. chelonae-M. abscessus complex and coagulase-negative Staphylococcus. The patient continued to improve after 3 weeks of antibiotic therapy. However, despite the initial improvement in the ESI, the M. chelonae-M. abscessus complex continued to grow, and amikacin was added intravenously. Despite continued treatment, the ESI did not resolve, and the catheter was removed after 4 months of therapy. Despite unusual exist-site infections with rapidly growing AFBs, both patients continued continuous ambulatory peritoneal dialysis (CAPD) while undergoing treatment for ESI. Catheters were left intact, as improvement was initially seen with no evidence of tunnel infection or peritonitis. Rapid-growing AFB should be considered another possible causative agent for ESI. Two cases of atypical mycobacterial exit-site infection are presented to illustrate the difficulties in managing this complication of peritoneal dialysis. Ofloxacin--or other quinolones--may provide a better spectrum of coverage when choosing empiric therapy in patients presenting with ESI.

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We report four episodes of non Candida albicans peritonitis (NCAP) in 3 patients on continuous ambulatory peritoneal dialysis (CAPD). Risk factors for NCAP included diabetes mellitus and prior antibiotic use in half of the cases. The antibiotic treatment was prescribed for exit-site infection (ESI) or peritonitis in the patient. Treatment for NCAP included antifungal therapy with oral fluconazole or intravenous amphotericin B. The NCAP resulted in catheter loss in 100% of the patients over time. Initial catheter salvage in one patient was followed 6 months later by catheter loss following treatment of a bacterial peritonitis that was complicated by the development of Candida (Torulopsis) glabrata peritonitis unresponsive to treatment with intravenous amphotericin B. Although the literature suggests that Candida peritonitis responds to oral fluconazole with and without catheter removal, this series suggests that the treatment of NCAP includes removal of the peritoneal dialysis catheter with appropriate antifungal agents.

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In this preliminary study we measured maximum walking distance and walking time on four consecutive days in 29 patients with clinically stable multiple sclerosis (MS). Patients were included in the study if they could achieve a maximum unaided walking distance of 100 up to 500 m. Our results showed a certain day-to-day variability of maximum walking distance, in some cases meaning changes up to 1.5 points in the expanded disability status scale (EDSS), which could be misinterpreted as a progression of the disease. Simultaneous measurements of maximum walking time showed a similar variability, unlike the mean walking speed which turned out to be more stable. Our results therefore suggest that scoring of MS patients should not be based on one single measurement of the maximum walking distance. The more reliable parameter appears to be the mean walking speed.

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The index patient is a 23-year-old female with end-stage renal disease (ESRD) secondary to chemotherapeutic agents. Continuous cycling peritoneal dialysis (CCPD) has been the renal replacement therapy for the past 5 years since a failed cadaveric renal transplant. Past medical history was significant for diabetes mellitus, hypertension, anemia, bilateral subclavian vein thrombosis with superior vena cava syndrome, secondary hyperparathyroidism, leukemia (at age 8), and hyperlipidemia. On presentation, soft tissue nodules were noted in the anterolateral surfaces of the legs. After 3 months of continued low-calcium-dialysate CCPD, calcitriol, and oral phosphate binders, a 2 x 3 cm nodule was noted on the posterior aspect of the thorax at the scapula. The only complaint at this time was shoulder pain at the acromioclavicular joint. Radiological examination revealed a 3 x 4 cm soft tissue opacity in the superior segment of the left lower lobe laterally. Despite a prior subtotal parathyroidectomy, phosphate binders, and calcitriol, the parathyroid hormone levels continued to increase, with development of tumoral calcinosis, worsening renal osteodystrophy, and calciphylaxis. Computed tomography examination revealed extensive soft tissue calcification consistent with tumoral calcinosis. An ulcerative lesion (1 cm) developed on the lateral aspect of the upper thigh owing to warfarin necrosis versus calciphylaxis. At this time, the phosphate binder was changed from calcium acetate to sevelamer hydrochloride. Aggressive wound treatment and aggressive calcium and phosphate control added to the treatment regimen has resulted in healing of the single ulcer and a decrease in the size of the tumoral lesions. In conclusion, early recognition and aggressive treatment of calciphylaxis can result in reduced morbidity and mortality from calciphylaxis in ESRD patients.

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Only 15 cases of any etiology of Neisseria meningitidis peritonitis have been reported in the world literature since the first case in 1917. We report the first case in a continuous ambulatory peritoneal dialysis (CAPD) patient presenting with abdominal pain and cloudy peritoneal dialysis fluid. A lumbar puncture was normal. The patient died despite therapy with ceftriaxone. Autopsy confirmed this was a case of primary N. meningitidis peritonitis. Of the 15 cases of N. meningitidis reported as a cause of peritonitis, 9 patients were less than age 35 with no underlying diseases. Five cases were associated with cirrhosis or alcohol abuse. Two cases were associated with meningitis, and 1 patient was on steroid therapy for systemic lupus erythematosus. Nine of 15 patients recovered. In conclusion, N. meningitidis should be considered as another rare cause of peritonitis in patients on CAPD.

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