UPDATE ON FUNGAL PERITONITIS AND ITS TREATMENT Matuszkiewicz-Rowinska, Joanna
Peritoneal dialysis international,
02/2009, Letnik:
29, Številka:
Supplement_2
Journal Article, Conference Proceeding
Recenzirano
Department of Nephrology, Dialysis and Internal Diseases, The Medical
University of Warsaw, Warsaw, Poland
Correspondence to: J. Matuszkiewicz-Rowinska, Department of Nephrology,
Dialysis and ...Internal Diseases, The Medical University of Warsaw, ul. Banacha
1a, Warsaw 02-097 Poland.
jotmatrow{at}o2.pl
Fungal peritonitis (FP) is a rare but potentially fatal complication of
chronic peritoneal dialysis (PD), associated with high morbidity and mortality
ranging between 20% and 30%. If not leading to death, the inflammatory process
usually causes irreversible damage to the peritoneal membrane with subsequent
dropout from PD therapy. Fungal peritonitis accounts for 3% – 6% of all
peritonitis episodes; however, in some areas, the numbers can be much higher.
The most common cause of the disease is Candida , predominately C.
albicans, C. parapsilosis , and—more recently— C.
glabrata ; other yeasts and filamentous fungi such as Aspergillus,
Paecilomyces, Penicillium , and Zygomycetes are found, but much
less frequently. The main factors associated with the development of FP
include previous antibiotic therapy, particularly for bacterial peritonitis,
when two important operative mechanisms coincide: fungal overgrowth in the
gastrointestinal tract and declining peritoneal defense because of
peritonitis.
The management of FP poses a difficult challenge. Prompt initiation of
therapy is critical, but no typical clinical picture has emerged, and the
infecting organism can be difficult to isolate. The approach to the disease
has changed considerably in recent years, and the 2005 guidelines from the
International Society for Peritoneal Dialysis list FP as a strong indication
for immediate catheter removal with temporary hemodialysis. The conventional
antifungal regimens include fluconazole, amphotericin B, and flucytosine alone
or in combination, optimally based on fungal sensitivities. The newer agents
such as caspofungin and voriconazole have the potential to alter treatment
strategies for FP, but further studies are required to clarify the precise
role of these agents in this group of patients.
KEY WORDS: Fungal peritonitis; peritonitis prophylaxis; peritoneal catheter removal.
Background: Tumor lysis syndrome (TLS) is an oncologic emergency due to a rapid break down of malignant cells usually induced by cytotoxic therapy, with hyperuricemia, hyperkalemia, ...hyperphosphatemia, hypocalcemia, and serious clinical consequences such as acute renal injury, cardiac arrhythmia, hypotension, and death. Rapidly expanding knowledge of cancer immune evasion mechanisms and host-tumor interactions has significantly changed our therapeutic strategies in hemato-oncology what resulted in the expanding spectrum of neoplasms with a risk of TLS. Summary: Since clinical TLS is a life-threatening condition, identifying patients with risk factors for TLS development and implementation of adequate preventive measures remains the most critical component of its medical management. In general, these consist of vigilant laboratory and clinical monitoring, vigorous IV hydration, urate-lowering therapy, avoidance of exogenous potassium, use of phosphate binders, and – in high-risk cases – considering cytoreduction before the start of the aggressive agent or a gradual escalation of its dose. Key Messages: In patients with a high risk of TLS, cytotoxic chemotherapy should be given in the facility with ready access to dialysis and a treatment plan discussed with the nephrology team. In the case of hyperkalemia, severe hyperphosphatemia or acidosis, and fluid overload unresponsive to diuretic therapy, the early renal replacement therapy (RRT) should be considered. One must remember that in TLS, the threshold for RRT initiation may be lower than in other clinical situations since the process of cell breakdown is ongoing, and rapid increases in serum electrolytes cannot be predicted.
Urinary tract infections (UTIs) are common in pregnant women and pose a great therapeutic challenge, since the risk of serious complications in both the mother and her child is high. Pregnancy is a ...state associated with physiological, structural and functional urinary tract changes which promote ascending infections from the urethra. Unlike the general population, all pregnant women should be screened for bacteriuria with urine culture, and asymptomatic bacteriuria must be treated in every case that is diagnosed, as it is an important risk factor for pyelonephritis in this population. The antibiotic chosen should have a good maternal and fetal safety profile. In this paper, current principles of diagnosis and management of UTI in pregnancy are reviewed, and the main problems and controversies are identified and discussed.
Acute kidney injury (AKI) is a frequent and serious complication of orthotopic liver transplantation (OLT), with a significant impact on mortality, graft survival, and chronic kidney disease. ...Currently, the diagnosis of AKI is based on changes in serum creatinine, which is a late marker, usually rising when there is already significant damage to the renal parenchyma. During the last 2 decades, various biomarkers have been studied in many clinical situations, mostly after cardiac surgery, in drug-induced AKI, or in sepsis. The present article summarizes the data on those biomarkers that have been evaluated for the prediction of AKI in patients undergoing OLT.
The peritoneal dialysis (PD) urgent-start pathway, without typical 2-week break-in period, was meant for late-referral patients able and prone to join PD-first program, with its main advantages such ...as: keeping the vascular system intact, preserving their residual renal function and retaining life-style flexibility. We compared the short- and long-term outcomes of consecutive 35 patients after urgent- and 94 patients after the planned start of PD as the first choice.
The study included all incident end-stage renal disease patients starting PD program between January 2005 and December 2015, classified into two groups: those with urgent (unplanned) and those with elective (planned) start. Urgent PD was initiated as an overnight automatic procedure (APD) with dwell volume gradually increased, and after 2-3 weeks, target PD method was established.
The mean time between catheter implantation and PD start was 3.5 ± 2.3 in urgent and 16.2 ± 1.7 days in planned-start groups (
< 0.00001). 51% of the patients in the urgent-start group required PD during first 48 h after catheter insertion. Mean follow-up of 17.6 ± 11.09 months (median: 19.0) was in the urgent-start group and 28.6 ± 26.6 months (median: 19.5) in the planned-start group. The early mechanical complications were observed more often in the urgent-start group (29 vs. 4%,
= 0.00005). The only significant predictors of early mechanical complications were serum albumin (
= 0.02) and time between the catheter insertion and PD start. The first year patient survival and technique survival censored for death and kidney transplantation were not significantly different between groups. In Cox proportional analysis the independent risk factors for patient survival as well as for method and patient survival appeared Charlson Comorbidity Index CCI (HR 1.4;
= 0.01 and 1.24;
= 0.02) and time from catheter implantation to PD start with HR 5.11;
= 0.03 and 4.29;
= 0.04 for <2 days, while time >14 days lost its predictive value (
= 0.07).
Peritoneal dialysis may be a feasible and safe alternative to HD in patients who need to start dialysis urgently without established dialysis access, with an acceptable complications rates, as well as patient and technique survival.
Intraoperative Dialysis During Liver Transplantation Kościelska, Małgorzata; Matuszkiewicz-Rowińska, Joanna; Zieniewicz, Krzysztof ...
Transplantation proceedings,
October 2020, 2020-Oct, 2020-10-00, 20201001, Letnik:
52, Številka:
8
Journal Article
Recenzirano
Orthotopic liver transplantation (LT) is a technically complex surgical procedure associated with a major risk of hemodynamic instability and metabolic derangement, especially in patients with ...coexisting renal dysfunction. Some centers have applied intraoperative renal replacement therapy (ioRRT) to support patients with preoperative renal failure and prevent critical complications. Although there is a strong theoretical rationale for this treatment, there remains a paucity of definite data demonstrating its benefits.
This was a retrospective observational study of all adult patients undergoing intraoperative dialysis in our center from January 2010 till December 2016.
The study group consisted of 88 patients with a mean MELD score of 31.4. Six patients underwent simultaneous liver and kidney transplantation. Forty-four (50%) recipients were admitted to the intensive care unit before transplantation, and 19 (21.6%) needed mechanical ventilation. Twenty-eight (31.8%) of the procedures were retransplantations, and 40 (45.4%) patients had been undergoing renal replacement therapy before LT. The mean preoperative serum creatinine was 2.82 ± 1.13 mg/dL.
The majority of patients (54.5%) was operated on using the veno-venous bypass technique. The mean arterial blood pH and potassium levels after reperfusion were 7.2 ± 0.12 and 4.04 ± 0.95 mmol/L, respectively. Postreperfusion syndrome (PRS) occurred in 11 (13.9%) patients in whom dialysis started at least 15 minutes before reperfusion. Dialysis circuit clotting occurred in 9.1% of cases. There were no other adverse events of ioRRT.
Our data suggests that intraoperative dialysis in severely ill patients with a high MELD score is safe and effective. Lower than expected PRS occurrence needs to be confirmed in a study with a control group.
•Intraoperative dialysis during liver transplantation in severely ill patients with a high MELD score and elevated serum creatinine is safe and feasible.•Patients treated with intraoperative dialysis had stable potassium levels during liver transplantation.•Lower-than-expected postreperfusion syndrome occurrence needs to be confirmed in a study with a control group.
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•Flow analysis systems for optical determination of urea has been developed.•The systems are dedicated for dialysate urea nitrogen determination.•The systems have been validated with ...real samples from hemodialysis treatments.
Three compact flow analysis systems based on flow-through optoelectronic devices and microsolenoid pumps and valves dedicated for determination of urea in effluent liquid produced by artificial kidney in the course of hemodialysis treatments have been developed. The developed photometric devices operate according to paired detector diode principle. For the first flow analysis system an optoelectronic urea biosensor based on pH-sensitive film enzymatically modified with urease has been applied. In the second system open-tubular urease biosensor and optical detector of ammonia by Berthelot reaction have been used. The third non-enzymatic analytical system is based on optoelectronic detector of the product formed in reaction of urea with modified Ehrlich reagent. The analytical utility of developed flow analysis systems has been tested with real samples of spent dialysate. The results of dialysate urea nitrogen determination are comparable with those obtained using reference off-line method recommended for clinical analysis. Advantages and drawbacks of developed prototypes have been compared and discussed.
Simultaneous liver and kidney transplants (SLKT) represent 1.1% of all liver transplants in Poland. Patients undergoing SLKT experience a longer operation time and concurrent kidney dysfunction may ...aggravate metabolic derangement associated with the procedure. The benefits of intraoperative dialysis (ioHD) in these patients have not been determined.
A retrospective observational study of all adult patients undergoing SLKT in our center from January 2009 till December 2016.
Study group consisted of 10 patients with End-Stage Kidney Disease (0.9% of all liver transplants): 6 patients treated with ioHD during SLKT (group 1) and 4 patients managed conservatively (group 2). All recipients were on chronic dialysis. The mean calculated Model for End-Stage Liver Disease score was 21 ± 0.9 in group 1 and 30 ± 9.5 in group 2 (P = .009). The mean preoperative serum potassium was 4.7 ± 0,6 mmol/L in group 1 and 3.97 ± 1,02 in group 2. Intraoperative serum potassium levels were comparable between the groups, but the maximum lactate and minimum bicarbonate levels were significantly worse in group 2. Postreperfusion syndrome occurred in no patient. Dialysis circuit clotting occurred in 50% of ioHD. Six patients (2 in group 1) required renal replacement therapy after SLKT; no patient was on dialysis on discharge. Three patients died within 1 year after surgery (2 in group 2).
No patient developed intraoperative hyperkalemia or postreperfusion syndrome. We observed a high frequency of circuit system clotting during ioHD. Clinical benefits of intraoperative hemodialysis during SLKT need to be determined in a larger study.
Background: Systemic sclerosis is an immune-mediated rheumatic disease characterized by vascular abnormalities, tissue fibrosis and autoimmune phenomena. Summary: Renal disease occurring in patients ...with systemic sclerosis may have a variable clinicopathological picture. The most specific renal condition associated with systemic sclerosis is scleroderma renal crisis, characterized by acute onset of renal failure and severe hypertension. Although the management of scleroderma renal crisis was revolutionized by the introduction of angiotensin-converting enzyme inhibitors, there is still a significant proportion of patients with poor outcomes. Therefore, research on establishing disease markers (clinical, ultrasonographical and serological) and clear diagnostic criteria, which could limit the risk of developing scleroderma renal crisis and facilitate diagnosis of this complication, is ongoing. Other forms of renal involvement in systemic sclerosis include vasculitis, an isolated reduced glomerular filtration rate in systemic sclerosis, antiphospholipid-associated nephropathy, high intrarenal arterial stiffness and proteinuria. Key Messages: Scleroderma renal crisis is the most specific and life-threatening renal presentation of systemic sclerosis, albeit with declining prevalence. In patients with scleroderma renal crisis, it is mandatory to control blood pressure early with increasing doses of angiotensin-converting enzyme inhibitors, along with other antihypertensive drugs if necessary. There is a strong association between renal involvement and patients’ outcomes in systemic sclerosis; consequently, it becomes mandatory to find markers that may be used to identify patients with an especially high risk of scleroderma renal crisis.
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